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Harvard Medical 



ALUMNI BULLETIN 



SPRING 1996 



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The 

Virtual 

Physician 



THE TRAGEDY ISN'T THAT 

SHE HAS CANCER. IT'S THAT 

WHEN THIS PICTURE WAS 

TAKEN SHE WAS MISSING 

HER TREATMENT. 



It's sad, but true. 
You see, even 
thoush medical 
science has siven 
more cancer 
Datients more 
iope than ever 
before, one of the 
most critical 
challenses facins 
these people is 
simply settins to 
their treatments. 
But you can help. And we hope you will. 
^. Throush the American Cancer Society's Road To 
Recovery prosram, you can volunteer to 

drive a cancer patient to and from 
?^^^ treatment. And, in turn, help them 
enjoy a fuller, lonser life. 
To find out more, call your American 
Cancer Society at 1 -800-ACS-2345. 
Because the only thins sadder than 
this picture is that we have more of 
them. 




m 

J^-^ 



AMERICAN 
V CANCER 
f SOCIETY' 

THERE'S NOTHING 
MIGHTIER THAN THE SWORD 



Spring 1996 
Volume 69 Number , 



Harvard Medical 



ALUMNI 



BULLETIN 




Cover photo by Stuart Darsch 



14 The Next Generation 

byRobeitA. Greenes 

Health care has met cyberspace and 

will never be the same. 

20 Medicine On-Line 

by Jerome Kassirer 

More revolutionary than the 

current restructuring in health care 

may be cultural changes due to the 

computer. 

22 Solitaire Confinement 

by William Ira Bennett 

What this country needs as badly as 

a V-chip is a G-chip to block out 

seductive computer games. 

The Giant Brainstorm 

by Ellen Barlow 

27 HMS Spins a Web 

by Terri L. Rutter 

The medical school's on-line face 

to the world. 

elicit Trip Through the Brain 

by Ellen Barlow 

Getting Started 

by Tern L. Rutter 

32 Operating in 3-D 

by Ellen Barlow 

Real-time image-guided surgery is 

a virtual reality. 

36 Tel-a-Doctor 

by TeiTi L. Rutter 
Telemedicine may be creating a 
global medical village. 

40 Digital Clinic 

by Luke Sato 

Using multimedia in case-based 

learning and beyond. 

Slight in Hand 

by Teiri L. Rutter 



44 Brave New Interviewer 

by Warner Slack 

The history and dynamics of using 

computers for patient interactions. 

50 The Senior Set on the Net 

by George Richardson 

Vistas and valleys on the information 

highway. 

Departments 

3 Letters 

4 Pulse 

Geriatric education, new Institute of 
Medicine members, second-year 
show, new professorships, HST 25th 
anniversary, HMS and Japan exchange 
students, center to study drug abuse 
and managed care, first Excellence in 
Mentoring Award, center for mini- 
mally invasive surgery opened, 
Howard Hughes Medical Institute 
grant. 

10 President's Report 

by Stephanie H. Pincus 

11 On the Quadrangle 

HMS-BI Healthcare Foundation, 
juncture of law and medicine. 

53 Alumni Notes 

59 In Memoriam 

Alexander Bill 
Lewis Dexter 

62 Death Notices 



Inside hmab 



Harvard Medical 



A L u M N 



BULLETIN 



In the last year or so, several of my patients have said something 
like the following: "I read about those drugs on the Web, and I 
really don't want to take one of them" or "Do you think I should 
take X? I read about it on the Web." Thus, what only recently 
seemed futuristic to me is starting to look very much like the pre- 
sent. I don't suppose the essays in this edition of the Bulletin will 
be out of date by the time this issue reaches you, but I confess they 
seem less visionary than when we first started reading the manu- 
scripts. 

As Robert Greenes contends, information is becoming radical- 
ly less centralized in the new world of the Internet. In many ways, 
this will doubtless be a Good Thing, though from time to time, it 
may also be problematic. To pursue my humble example, most 
physicians are accustomed to having patients come in with infor- 
mation from a current best-seller (in my case. Listening to Prozac or 
Driven to Distraction). It is quite a different experience when this 
information comes from a community of patients describing their 
experience on the Web. 

There can be little doubt that the Web will increasingly 
"democratize" medical information. Jerome Kassirer, editor of The 
New England Journal of Medicine, sketches a view of how this might 
work, and of how medical care may overcome certain limitations 
of space and time through the burgeoning capacity of computer 
and network systems. 

Other contributors to this issue of HMAB describe various ways 
in which new computer technology is changing the reach of our 
knowledge and understanding. For most, this takes the form of a 
dramatic enhancement of intellectual resources or mental capacity. 
(I offer a minor autobiographical exception to this trend.) 

With this issue of HMAB we must say goodbye to Associate 
Editor Terri L. Rutter. We have greatly benefited from her prose, 
passion, vision and humor. Ms. Rutter has led us into the myster- 
ies of the Internet, and she was the moving spirit behind the issue 
celebrating 50 years of women at HMS. Both in signed articles and 
in tactful editing she has helped to shape this magazine. We thank 
her and wish her all the best as she moves into the next phase of 
her writing career. 

William Ira Bennett ^68 



Editor-in-chief 

William Ira Bennett '68 

Editor 

Ellen Barlow 

Associate Editor 

Terri L. Rutter 

Assistant Editor 

Sarah Jane Nelson 

Editorial Board 

Elissa A. Ely '88 
Melinda Fan '96 
Robert M. Goldwyn '56 
Joshua Hauser '95 
Paula A. Johnson '84 
Victoria McEvoy '75 
James J. O'Connell '82 
Gabriel Otterman '91 
Deborah Prothrow-Stith '79 
Guillermo C. Sanchez '49 
J. Gordon Scarmell '40 
Eleanor Shore '55 
John D. Stoeckle '47 
Richard J. Wolfe 

Design Direction 

Sametz Blackstone Associates, Inc. 

Association Officers 

Stephanie H. Pincus '68, president 
Suzanne Fletcher '66, president-elect i 
Robert S. Lawrence '64, president-elect 2 
Roman W. DeSanctis '55, vice president 
Nancy A. Rigotti '78, secretary 
Arthur R. Kravitz '54, treasurer 

Councillors 

Kenneth Roland Bridges '76 
David P. Gilmour '66 
Katherine L. Griem '82 
Dana Leifer '85 
Sharon B. Murphy '69 
Gilbert S. Omenn '65 
Bruce J. Sams Jr. '55 
John B. Stanbury '39 
Lorraine Dudley Stanfield '87 

Director of Alumni Relations 

Daniel D. Federman '53 

Representative to the Harvard Alumni Association 

Chester d'Autremont '44 

ID Statement: 

The Hai-uard Medical Alumni Bulletin is published 
quarterly at 25 Shattuck Street, Boston, AL\ 02 1 15 
© by the Harvard Medical Alumni Association. 
Telephone: (617) 432-1548. Email address: 
bulletin@warren.med.harvard.edu. Third class postage 
paid at Boston, Massachusetts. Postmaster, send form 
3579 to 25 Shattuck Street, Boston, MA 02 11 5, 
ISSN 0191-7757. Printed in the U.S.A. 



Harvard Medical Alumni Bulletin 



John Schott, M.D. 

HMS '66 

Investment Advisor 

Managed accounts, 

retirement accounts, 

family trusts 

Dr. Schott provides highly 

personalized investment 

management to individuals, 

families and institutions 

His unique approach and 

established record merit your 

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Schott Investment 
Corporation 

Publisher of The Schott Letter 

120 Centre Street 

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• 

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SEC and Commonwealth of 

Massachusetts 



Letters 




Obstructed View 

The articles on the topic of HMOs and 
so called managed care (Winter '96) 
were timely and very interesting; how- 
ever, some pages were very trying to 
read. Pages printed on a gray back- 
ground of varying density were diffi- 
cult to see clearly, especially under 
artificial light. And lastly, "Changes in 
the Amphitheatre" in three divided 
columns on each page added to the 
frustrations of trjdng to read my 
favorite alumni magazine. We older 
alums have trouble enough with our 
sight. 

Are we tttying too hard to be 
trendy? 

Albert P. Ley '^^B 

Grammatical Error 

A sentence in the recent issue (Winter 
'96, P56) reminds me of the old New 
Yorker quips: "Clement was a psychia- 
trist who specialized in the treatment 
of alcoholism on the staff of Buffalo 
General Hospital." 

Buffalo is a tough place to live but... 

Eugene E. Nattie '77 

Creative Support 

I was very interested in your column in 
the Winter '96 Bulletin announcing 
the arrival of Cushing Robinson to 
superintend the development cam- 
paign for HMS. I was heartened that 
HMS had chosen someone with experi- 
ence with the University of 
Pennsylvania Medical School's effort 
to realize what you sarcastically refer 
to as the "pipe dream" ['a fantastic 
notion or vain hope. ...from the fan- 
tasies induced by smoking opium'] of a 
tuition-fi-ee medical education for all 
students." 

There was insufficient detail to 
ascertain whether Robinson's $10 mil- 
lion allocation at Penn was enough to 
generate the full tuition equivalent for 
24 students, or whether it was merely 



the seed money for a larger sum. In 
any case, I remain confused by your 
assumption that $500 million would be 
required to render HMS tuition-free. 

Assuming that in today's market 
HMS could obtain a (tax-free) return on 
investment of at least 10 percent, 5 
percent would generate $25 million, 
enough to more than equal the annual 
tuition bills of 1,000 students (HMS has 
less than 700). I do not mean to befit- 
tle the task of raising such a sum; but 
by making it unnecessarily large, you 
inhibit any serious discussion of gener- 
ating funds for such a purpose. 
However, when the total cost of sup- 
porting a student for one year at HMS 
approaches the annual income of the 
average American family, novel solu- 
tions must be sought and tested with 
real urgency. 

It is ironic that in the same issue of 
the Bulletin, the Alumni Council is 
described as searching for "creative 
ways to deal with financial issues," 
without any reference to the UPenn 
(or any other) initiative. Further, HMS 
announces its pride in generating fel- 
lowships for junior faculty who, more 
than likely, need the income to help 
pay off their student loans! 

Instead of repetitive solicitations of 
money from alumni/ae to help the 
neediest students from drowning in 
debt while forcing more affluent fami- 
lies to subsidize tuition for those 
unable to pay, shouldn't HMS allocate 
vigorous development effort to obtain- 
ing hard money for a permanent 
endowment to defray tuition? 

In an era of declining income 
expectations for physicians (and 
increasing physician/physician mar- 
riage), what is Harvard teaching its 
students when it encourages them to 
aggravate their individual indebtedness 
by more than $100,000, or forces them 
to turn to their parents to scavenge 
money from retirement funds or sib- 



Spring 1996 



Letters 



Pulse 



lings' inheritances? Mixed with the joy 
of becoming a doctor will be the bit- 
terness of prolonged financial hard- 
ship. 

If creative thinking or new initia- 
tives — as well as funds — are wanting, I 
and other HMS graduates will always be 
eager to help. But I think that perenni- 
ally dunning us to offset tuition is 
merely a stopgap measure. It has no 
more grace, and far less moral weight, 
than assisting the homeless. It is time 
to reconsider our priorities so that 
they reflect a leadership role for 
Harvard with regard to the support, as 
well as the content, of medical educa- 
tion. 

Mark G. Perlroth '60 

Too Much Change 

I have put off this note (along with my 
reduced yearly donation), because it 
gives me great pain to compose this. 
While attending my 60th college 
reunion, I thought I would revisit 
Vanderbilt and see how things were 
going. It was like my walking into 
some East Asian school — no responses 
to my greetings and much jabbering in 
foreign tongues. 

Then came the "Making Herstory" 
issue (Spring '95) and the cover photo 
awakened me (very sadly) as to what 
was going on at Alma Mater. I am not 
prejudiced against women as doctors, 
but the takeover of the school by affir- 
mative action women students I can- 
not stand. 

Something is very amiss among 
those who guide the admissions policy 
of Harvard Medical School, and it is 
high time for a reversal of this trend. 

I had given a moderate sum to the 
school in my will, but I have had my 
lawyer delete this. I will not support 
this conversion. This upsets me very 
much, but if this is disloyalty, so be it. 

Wm. Neil Campbell Jr. '^8 



A Boost for Geriatric Medicine 

The geriatric education center, part of 
the Harvard Medical School Division 
on Aging, is developing a model edu- 
cation program that will broaden the 
scope of geriatric care. The program 
will train advanced-degree students in 
an interdisciplinary approach to geri- 
atrics, including primary care skills. 
Since 60 percent of all health care 
users are older than 65, almost every 
health care provider sees elderly 
patients and, according to Sue Levkoff, 
director of the Harvard Upper New 
England Geriatric Education Center, 
physicians need to pay more attention 
to giving this population adequate and 
well-rounded care. 

"The care of the older person 
demands this interdisciplinary per- 
spective because of complex health 
care needs that are exacerbated by 
social determinants and outcomes as 
well as environmental issues," says 
Levkoff. 



Barbara Berkman (left) and Sue Levkoff 



A $ 1 00,000 training grant from the 
John A. Hartford Foundation in New 
York will assist the school in the devel- 
opment of the education program. 
Levkoff, associate professor in social 
medicine, and Barbara Berkman, asso- 
ciate director of the geriatric education 
center and director of social work 
research at MGH, will coordinate the 
program's planning process. 

Under the grant, the geriatric edu- 
cation center is working with academic 
and clinical faculty within Harvard and 
at other educational institutions in the 
Boston area to develop and initiate 
four products: a clinical teaching path- 
way, an interdisciplinary curriculum 
for providing geriatric care in the clin- 
ical setting, interdisciplinary commu- 
nication tools, and a model for 
teaching patients and family members 
to participate in planning their own 
care. Ethical issues of geriatric primary 
care will be emphasized in all aspects 
of this education model. 



<M 




Harvard Medical Alumni Bulletin 



Felton Earls 



Robert Glickman 



Ferenc Jolesz 



David Livingston 



Institute Honors 

The Institute of Medicine of the 
National Academy of Sciences has 
appointed three new members from 
Harvard Medical School: Felton Earls, 
HMS professor of child psychiatry and 
HSPH assistant professor of human 
behavior and development; Robert 
Glickman, Herrman Ludwig Blumgart 
Professor of Medicine at HMS and 
chairman of the Department of 
Medicine at Beth Israel Hospital; and 
Ferenc Jolesz, HMS associate professor 
of radiology and director of the 
Division of Magnetic Resonance 
Imaging at Brigham and Women's 
Hospital. David Livingston, Emil Frei 
Professor of Medicine at HMS and 
chair of the research executive com- 
mittee at the Dana-Farber Cancer 
Institute, has been named to the 
National Academy of Sciences. 



Earls has been studying how such 
factors as poverty, social devaluation, 
physical and emotional abuse, and the 
breakdown of neighborhood commu- 
nities can put children at risk for men- 
tal and emotional disorders. He is the 
scientific director of the Project on 
Human Development in Chicago 
Neighborhoods, a long-term study of 
9,000 children and their families. 

Glickman has studied the metabo- 
lism and absorption of fats and 
lipoproteins for more than two 
decades. Gfickman and colleagues dis- 
covered that the small intestine pro- 
duces apoproteins that coat the various 
fat molecules as they travel in the 
bloodstream. His work has helped 
reveal how fat molecules make their 
way into the bloodstream from the 
diet, and underscores the important 
role of the intestine in hpoprotein 



metabolism. 

Jolesz has advanced imaging tech- 
niques used in neuroradiology to guide 
various surgical interventions. 
Recently, he spurred the development 
of an innovative magnetic-resonance 
operating environment that provides 
surgeons with real-time images of tis- 
sues deep inside the brain and other 
organs. (See story page 32.) 

Livingston studies the DNA tumor 
virus SV40 and how it promotes the 
cancerous growth of mammalian cells. 
Livingston's group has also isolated 
and started defining the function of a 
family of proteins that contribute to 
the growth of mammalian cells; his 
laboratory is part of an international 
effort to decipher the basic biochemi- 
cal mechanisms that the Rb protein 
uses to maintain normal cell behavior. 



The Second-Year Show 
expressed fears of debt in 
dance and song: 

When the Newt is in the 
Senate House 
And HMOs are on the rise 
MBAs will mold health care 
And welfare's swift demise. 

This is the dawning of the 
Age of Indebtedness. 




Spring 1996 



Pulse 




Judith Palfrey and T. Berry Brazelton 



Dean Daniel Tosteson is flanked by Fritz Bach (left) and Anthony Monaco. 



Three New Professorships Filled 

With the finale of 1995 came the cele- 
bration of three new professorships 
and the selection of their first incum- 
bents. November was a busy month in 
the faculty room, first feting two pro- 
fessors in transplantation surgery, 
Fritz H. Bach '60 as the Lewis 
Thomas Professor of Surgery and 
Anthony P. Monaco '56 as the Peter 
Medawar Professor of Surgery, both 
endowed by the Sandoz Pharmaceut- 
ical Corporation. Then a week later, 
Judith Palfrey, chief of the Children's 
Hospital division of general pediatrics, 
was saluted as the T. Berry Brazelton 
Professor of Pediatrics. 

Bach, who is director of the Sandoz 
Center of Immunobiology at the New 
England Deaconess Hospital, did his 
internship and medical residency at 
New York University, where he said, 
"Lewis Thomas became my friend and 
mentor, who inspired by example by 
providing wisdom and encourage- 
ment." In 1964, under Thomas's guid- 
ance, Bach developed the mixed 
lymphocyte culture as a test for tissue 
compatibility for transplantation, an 
assay that is still used for tissue tj^Ding. 
Though famous for his poetic essays, 
Thomas '37, who died in 1993, was 
renowned also as a medical scientist 
who wrote prolifically on a variety of 
interests, many concerned with the 
host response to infection. 

The other professorship in surgery 
is named for Peter Medawar, a pioneer 
of transplantation science and Nobel 
laureate for his discoveries about rejec- 
tion and "privileged" times for trans- 
plantation. Though a zoologist, "Peter 
Medawar was driven in his research to 
help people solve clinical problems," 



said Monaco, in his tribute to the man 
whose name he will carry on his pro- 
fessorship. Monaco did not personally 
know Medawar, who died in 1987, but 
he said that he has pursued Medawar's 
line of inquiry into tissue transplanta- 
tion and its therapeutic applications 
for more than 30 years. Monaco is 
chief of organ transplantation at the 
Deaconess. 

T. Berry Brazelton is a household 
name for those who have children, and 
his name will now grace the third new 
professorship. Renowned for his work 
in child development and for creating 
the neonatal behavioral assessment 
scale, Brazelton has written 26 books 
and more than 180 scientific articles 
and chapters. He was chief of 
Children's Hospital's child develop- 
ment unit from 1972 to 1989 and is 
professor of pediatrics emeritus. 

Judith Palfi-ey is a pediatrician who 
has devoted her professional career to 
improving community health care ser- 
vices for children. She recently pub- 
lished the book Community Child 
Health: An Action Flan for Today. 

"To be associated with T. Berry 
Brazelton's name has got to be the 
greatest honor," said Palfrey. "This is 
an opportunity for us to listen and to 
put the child back in the center, back 
in the family, back in the community." 



HST Silver Jubilee 

The Harvard-MIT Division of Health 
Sciences and Technology (hst) wel- 
comed back 43 graduates for a 25th 
anniversary celebration December 7 
and 8, 1995. The HST Silver Jubilee 
honored the division's founders, show- 
cased the achievements of its alumni, 
and anticipated the future of the divi- 
sion through discussion of its educa- 
tional and research activities. 

HST is an interdisciplinary collabo- 
rative effort of HMS and MIT estab- 
lished in 1970 to focus science and 
technology on human health prob- 
lems. "In 1970 combining science and 
engineering with compassion and care 
for patients was an untried idea," said 
Irving London '39, the founding 
director of HST for 1 5 years and a pro- 
fessor emeritus at both HMS and MIT. 
"We had to integrate two universities 
with different strengths and decidedly 
different cultures." 

HST students opt among programs 
that lead to an MD, a combined 
MD/phD or just a Pho. In the history of 
the program there have been 500 
graduates who received MDs (some of 
whom also earned PhDs) and about 70 
who got a PhD alone. HST is one of the 
five academic societies at HMS, 
although for the first two preclinical 
years, HST students attend separate 
courses, at both MIT and HMS. They 
then join the rest of the medical stu- 
dents on the wards for clerkships. 

The intent of the HST curriculum is 
to "educate leaders in academic medi- 
cine and the biomedical sciences" and 
to impart a "quantitative and molecu- 
lar understanding of pathophysiologic 
processes." As summarized in a previ- 
ous course catalog: "Graduates appre- 
ciate the relevance of fluid mechanics 



Harvard Medical Alumni Bulletin 




Walter Abelman 



Irving London 



and mathematical modeling to the 
understanding of cardiovascular patho- 
physiology; they are exposed to the 
potential contributions of artificial 
intelligence and robotics to the under- 
standing of the human nervous system; 
and they are able to integrate the con- 
cepts of molecular biology and bio- 
chemistry into their care of patients." 

The HST celebration commenced 
with a reception and dinner at the 
Museum of Science, featuring 
speeches by London and Walter H. 
Abelmann, a former HST director and 
HMS professor of medicine emeritus. 
A full day of scientific presentations by 
15 HST alumni followed on Friday, 
culminating in the silver jubilee dinner 
at the MIT Faculty Club, at which 
those who played a major role in HST's 
history were honored: London, 
Abelmann, the late Robert Ebert, for- 
mer dean of HMS, Richard Kitz, a for- 
mer director of the HST program, and 
Walter Rosenblith, MIT professor 
emeritus. 

A dedicated few stayed on Saturday 
morning, as it began to snow, where 
over breakfast they discussed the 
future of the division. Michael 
Rosenblatt '73 and Roger Mark '65, 
who are now co-directors of the divi- 
sion, and Associate Director Joseph 
Bonventre '76 led the discussion. They 
talked about the most recently estab- 
lished programs — a doctoral program 
in speech and the hearing sciences; and 
the Radiological Sciences Joint 
Program — and asked for input on the 
direction of the division in face of 
changes in the health care field. 
Whatever happens, new initiatives are 
being planned and, as Rosenblatt 
noted, "We're looking forward to our 
golden jubilee." 



From Here to Japan 

In June of last year, six students from 
Harvard Medical School served as 
ambassadors of the New Pathway to 
the University of Tokyo. For five days 
the HMS students were paired with 
eight Japanese medical students, shar- 
ing sometimes vastly differing perspec- 
tives on everything from medical 
education and patient care to food and 
birds. (One Japanese student com- 
mented that he had never realized 
before there was a difference between 
a dirty pigeon and a peaceful dove — 
they're the same species in Japanese — 
and why Americans would order sushi 
without the fish.) In October 1995 the 
Japanese students visited HMS to wit- 
ness medicine the American way. 

Under the faculty advisorship of 
Robert Fletcher '66, professor of 
ambulatory care and prevention, and 
Richard Heller, professor of commu- 
nity medicine at the University of 
Newcastle Faculty of Medicine and 
Health Sciences in Australia, HMS stu- 
dents demonstrated the New Pathway- 
style of case-based, small-group 
instruction by discussing cases used in 
second-year tutorials. It was quite a 
learning experience for both groups, as 
one Japanese student said in his evau- 
lation of the program: "The American 
students ask many questions and 
actively express their own opinions." 
This behavior is in marked contrast to 
how another student described his 
experiences in medical school: "We 
are apt to be passive and sleepy in the 
Japanese type of lecture." 

The students also planned a joint 
project whereby they examined the 
entire regimen of care for a patient 
with colorectal cancer, from discus- 



sions about how to prevent the condi- 
tion to the death of the afflicted 
patient. Again, the differences between 
the two systems of health care delivery 
were profound. In Japan, patients with 
cancer are frequently not told they 
have a terminal illness, and many stu- 
dents commented on how sharply that 
view contrasted with the perspective in 
this country, where the patient is told 
everything. 

The exchange program was the 
brainchild of Kiyoshi Kurokawa, pro- 
fessor of medicine and director of 
international academic affairs at the 
Univeristy of Tokyo. Kurokawa taught 
medicine in the United States for 14 
years before returning to Japan in 
1983. Since then, he has been inter- 
ested in initiating exchange programs 
between the United States and Japan 
so practitioners and students from 
each can gain understanding about the 
similarities and differences between 
the two countries. He had a particular 
desire to know more about HMS's New 
Pathway and thus, when a wealthy 
Japanese entrepreneur offered to fund 
the entire project with a grant from his 
company, the idea took flight. 

"We both taught each other 
equally, and we both had to learn to 
adapt to the other's ways," says Keri 
Gardner '96 in a booklet the Japanese 
students put together describing their 
experiences. "While it required much 
work, and much frustration, we did 
and for that I think we are all proud." 

Whether the project continues 
depends on continued funding. 



Spring 1996 



Pulse 



Managing Care for Drug Abuse 

The Harvard Medical School has 
joined forces with Brandeis University 
to study how drug and alcohol abuse 
and addiction are treated under man- 
aged care. The project will link HMS's 
Department of Health Care Policy 
with the Institute for Health Policy at 
the Heller Graduate School for 
Advanced Studies in Social Welfare at 
Brandeis. Richard Frank, HMS profes- 
sor of health economics, will co-direct 
the new effort, called the Brandeis/ 
Harvard Research Center for 
Managed Care and Drug Abuse 
Treatment, with Dennis McCarty, 
professor at Brandeis. The National 
Institute on Drug Abuse has granted 
the new center $4.5 million. 

Alcoholism and other forms of sub- 
stance abuse are chronic diseases 
requiring a commitment to long-term 
care, yet managed care programs are 
geared toward more acute care among 
a relatively stable patient population. 
With more and more people signing 
on to HMOs and the like, however, 
managed care plans will increasingly 
assume more responsibility for treating 
drug and alcohol abuse and addiction. 
The center hopes to provide some 
analyses about how that can best be 
achieved. 

"No one is quite sure about what 
methods lead to what effects," says 
Frank. "There's enough good experi- 
ence to give people a sense that it can 
be done right, but enough bad that 
there's concern." 

McCarty says he would like man- 
aged care providers to ask how they 
can better care for their patients with 
substance abuse — "questions that man- 
aged care organizations ask about all 
the care they provide." He also 
believes, he says, that substance abuse 
treatment centers funded by the public 
sector need to be more active in reach- 
ing out to managed care organizations 



to find ways they can work together. 
These treatment centers, which have 
considerable experience treating the 
unique problems of the noninsured or 
underinsured, become increasingly 
valuable as managed care organizations 
reach out to Medicaid patients. 

The center has embarked on three 
investigations, which will analyze data 
from 20 states in total: 

• tracking the development of 
"carve-out" arrangements, whereby 
funds for mental health services, 
including substance abuse care, are 
delineated or carved out from the rest 
of the plan. The center will determine 
how Medicaid and privately insured 
groups handle this payment method in 
their delivery of substance abuse ser- 
vices; 

• empirical studies on the financial 
incentives in contracts between pur- 
chasers and managed care organiza- 
tions and their effects on the costs and 
utilization of treatment services; 

• and measuring provider practice 
and performance by identifying treat- 
ment programs and measuring their 
effectiveness by the severity of condi- 
tions being treated. 

"The center will not only increase 
understanding of the substance abuse 
treatment system, it will identify the 
effects of managed care and improve 
the ability of policy makers and those 
who provide treatment to achieve the 
most appropriate and efficient care," 
says McCarty. 




Stephen Burakoff, professor of pediatrics at Dana-Farber 
Cancer Institute, was awarded tlie first Excellence in 
Mentoring Award by William Silen, dean for faculty devel- 
opment and diversity. 

Burakoff was chosen following a canvasing of faculty and 
students, which garnered over 500 nominations for 247 
faculty. In announcing the award to the Faculty Council, 
Silen read from a collection of comments made by facul- 
ty and students about Burakoff, including the following: 

"His ability to support diverse indreiduals in their 
careers, to help them through the confusing and often 
unsupportive environment in which we find ourselves, 
and to give generously of his own time and visibility for 
our benefit all make him an outstanding candidate for 
this award." 



Harvard Medical Alumni Bulletin 



Center Open for Minimally Invasive Sui^ery 

Four years ago Arthur Lage, HMS asso- 
ciate professor of surgery, invited sur- 
gical staff from the school's five 
affiliated hospitals to come together 
and discuss whether there was any 
interest in establishing a center for the 
research and practice of minimally 
invasive surgery. His idea was received 
with "a great amount of interest," and 
so he formed a working group to orga- 
nize and search for a funding source 
for this venture. U.S. Surgical Corp., 
maker of laparoscopic surgical instru- 
ments, answered the call and on 
December 6, 1995 the Harvard Center 
for Minimally Invasive Surgery 
opened. 

"This center is unique in that it's 
the largest and best designed as well as 
having the most ambitious program," 
of any of its kind in the country, boasts 
Lage. 

Laparoscopic surgery is performed 
with a miniature camera, which is 
inserted through a small incision. 
Guided by the images relayed from the 
camera as it searches its way through 
the body cavity — images that are then 
transferred onto an overhead display 
terminal — the surgeon is able to scope 
the afflicted part. Because there is no 
large opening of the body cavity, 
recovery time is usually much shorter 
than following traditional surgery. 

Currently, laparoscopic techniques 
are used successfully in five major 
areas: urology, ob/gyn, gastroenterol- 
ogy, general surgery and thoracic 
surgery. Lage hopes that research 
done at the center will lead to uses in 
other areas, as well as improvements in 
technique and also in the technology 
itself. Ainong the most recent advances 
he points to are the uses of minimally 
invasive procedures while the patient is 
undergoing MRI. 

"The latest laparoscopic cameras 
have a high resolution and the surgical 



equipment is becoming more minia- 
turized," says Lage. 

Located in 3,400 sq. ft. in the 
Seeley G. Mudd Building, the center 
allows for the centralization of the 
research and training of minimally 
invasive surgery for the first time. 
Before the center opened, each surgi- 
cal department had its own program, 
explains Lage. Centralized training 
standardizes and improves the learning 
experience for residents. The center 
also offers CME courses for practicing 
physicians. 

The center is outfitted with a surgi- 
cal suite, physiology laboratory, animal 
housing and an x-ray room. It also uses 
inanimate pelvic trainers and rubber 
torsos, equipped with realistic organs, 
with which residents and learning 
practitioners practice maneuvering the 
laparoscopic equipment. 



Howard Hughes Grant Awarded 

The Howard Hughes Medical 
Institute, the nation's largest private 
philanthropy, has awarded Harvard 
Medical School a $2.2 million grant, 
part of $80 million the institute is 
granting to schools around the coun- 
try. The money will support research 
at the interface of neurobiology and 
cell biology, "two of the most exciting 
areas in modern biomedical science," 
said Dean Daniel Tosteon '49. 

Gerald Fishbach, Nathan March 
Pusey Professor of Neurobiology, and 
Marc Kirschner, the Carl W. Walter 
Professor of Cell Biology, are working 
together on a joint program to recruit 
scientists, establish shared research 
facilities, and develop collaborative 
research programs. 



Arthur Lage (left)at the opening of the Center for Minimally Invasive 
Surgery with Carlos Labini and Leon Hirsch from U.S. Sui^ical and 
Cynthia Barlow, center coordinator. 




Spring 1996 



President's Report 

by Stephanie H. Pinais 



The snows had melted and floods 
abated by the time of the winter meet- 
ing of the Harvard Medical Alumni 
Council on Friday, January 26, 1996. 
Like all academic medical centers, 
Harvard is struggling with the issue of 
managed care and its implications for 
medical education. Questions raised 
include: 

• Should managed care principles be 
taught in the curriculum? 

• How should evaluation of patients 
be modified in keeping with the time 
management principles of managed 
care? 

• Should medical education be 
changed to include more population- 
based medicine? 

• How should the curriculum be 
adapted or revised in order to meet the 
new expectations for physician prac- 
tice? 

• What should medical students be 
taught about the role of allied health 
professionals, such as physician assis- 
tants and nurse practitioners? 

These questions stimulated lively 
discussion but no resolution. The 
comments and perceptions of the 
Alumni Council will be included, how- 
ever, in upcoming discussions at the 
medical school. The council had the 
opportunity to hear two recent gradu- 
ates. Glen Churtow '89 and Mark 
Hughes '86, bring insights from the 
local Boston area. Keep posted for fur- 
ther news on this stimulating and chal- 
lenging topic. 

Applications for first-year places at 
Harvard Medical School continue to 
climb upwards, with over 4,000 appli- 
cants for the class entering in the fall 
of 1996. Gerald Foster '51, associate 
dean for admissions, reported that 
each application is individually 
screened by a "pair of eyes," in order 
to assure that those unusual individuals 
who do not fit into computerized pro- 
files can be identified. Candidates of 



interest are offered interviews in 
Boston or other sites. Approximately 
160 to 180 non-Boston interviews are 
conducted by a Harvard Medical 
School representative along with local 
alumni. Any alumni interested in par- 
ticipating should contact Dr. Foster. 

Approximately 200 students are 
accepted for a class of 165. Harvard 
expects that the entering class next fall 
will again be more than 50 percent 
women, except for the HST program 
which is about two-thirds men. 

The LCME, the accrediting agency 
for medical schools, recently visited 
Harvard. James Adelstein '53, execu- 
tive dean for academic programs, 
reported that the visit went very well. 
Harvard was lauded for excellence in 
education, curriculum development, 
faculty advising, and the quality of stu- 
dent interaction — the students being 
eager to take charge of their own edu- 
cation. Concerns included scheduling 
items related to HST and the New 
Pathway, a lack of faculty diversity, 
and a lack of attention to pragmatic 
matters, such as OSHA and tuberculin 
tests. A great concern was the student 
debt, which the Alumni Council has 
previously reviewed. All medical 
schools increasingly will face the issue 
of reimbursement for educational 
activities. 

The business portion of the Alumni 
Council meeting dealt with the bud- 
gets (on target and modest) and the 
vital issue of inclusion of alumni. In 
order to encourage alumni participa- 
tion, mailing will include opportunities 
to volunteer for participation in vari- 
ous Harvard alumni activities. 
Involved participatory alumni is the 
goal of the Alumni Council. The ques- 
tion of linkage through the Internet, 
which would facilitate communication, 
was also reviewed. Look for further 
updates on this. Finally, Alumni Week 
is, as always, a subject of discussion. 



Any suggestions for programming or 
of any kind, should be forwarded to 
Dean Dan Federman '53. 

A glimpse of the current graduating 
class and the experiences of some of its 
individuals was provided by Edward 
Hundert '84, associate dean for stu- 
dent affairs. As expected, a bright and 
talented group of students will be 
graduating. The majority of those on 
the Alumni Council were awed by 
their achievements and accomplish- 
ments. An incidental discovery during 
this discussion was that Harvard 
Medical School keeps your admission 
essay on file forever. If you ever won- 
dered how you "stacked up" to your 
original goals and expectations, some- 
where in storage is your original essay. 
Whether this is retrievable on demand 
is uncertain, but we will let you know. 

Finally, on behalf of all the Alumni 
Council, we thank each of you for your 
continued generous giving. Harvard 
Medical School receives better support 
from its graduates than any other med- 
ical school. You are an appreciated and 
important group. Your ideas, thoughts 
and comments, in addition to your 
financial contributions, are notewor- 
thy. 

I look forward to seeing many of 
you at our June reunion. 

Stephanie H. Pinciis '68 is professor and 
chair of the Department of Dermatology 
at SUNT Buffalo. 



Harvard Medical Alumni Bulletin 



On the Quad 



HMS-BI Healthcare Foundation 

The Beth Israel Hospital has boldly 
strengthened its commitment to med- 
ical student education through a joint 
venture with Harvard Medical School, 
the formation of the HMS-BI 
HealthCare Foundation for Research 
and Education. 

By elevating the visibility of teach- 
ing and research, the two institutions 
hope to create a model for preserving 
and funding the academic mission of 
medicine, whose survival amidst the 
revolutionary changes in health care 
delivery has been threatened. It is the 
hope of Dean Daniel Tosteson '49 
that similar arrangements can be made 
with the medical school's other teach- 
ing affiliates. 

"The relationship between the fac- 
ulty and clinical departments as they 
work towards their academic, as com- 
pared with their clinical care, missions 
is changing rapidly," says Tosteson. 
"Both missions require energetic and 
creative leadership. The new founda- 
tion aims to provide such leadership 
for the academic mission. We are for- 
tunate that Professor Michael 
Rosenblatt will serve as executive of 
the foundation." 

Mitchell Rabldn '55, president and 
CEO of the Beth Israel Hospital, was 
the first to respond to the dean's over- 
tures and concern for medical scholar- 
ship because, he says, "we felt his ideas 
were on the mark and very timely." As 
Rabkin explains it: "The core 'busi- 
ness' of clinical medicine — payment 
issues, cost control, clinical proto- 
cols — puts a drain on the time and 
attention of each chief of service. But 
the core mission is more demanding as 
well. Teaching is no longer really done 
on sedentary patients; ambulatory 
patients enlarge not only the geo- 
graphic venue but also the faculty, and 
place new demands on curriculum 
content, and on monitoring and coor- 




Mitchell Rabkin 



dinating faculty." 

Research is increasingly demanding 
as well, he adds. "As we shift from 
organ and tissue-focused investigations 
in anatomy, physiology and biochem- 
istry to a focus on genetic and molecu- 
lar mechanisms, there needs to be 
stewardship by the chair that involves 
broader overview and greater insight, 
if scholarly excellence is to be main- 
tained." 

Conversations between Tosteson 
and Rabkin led to the formation of a 
small working group, where the con- 
cept of pooling resources to form a 
joint venture emerged. The idea is for 
the foundation to be headed by some- 
one whose top priority is finding and 
directing new funding for education 
and research, facilitating the move- 
ment of medical student education 
into outpatient settings, and helping to 
implement solutions to such issues as 
teaching equity and reward. For the 
hospital, says Rabkin, this person is 
"someone who will focus on the core 
academic mission of teaching and 
research, and thereby assist the chairs 
through co-management of these 
responsibilities, in a manner that does 
not diminish the chairs' responsibili- 
ties." 

The person who has taken on the 
challenge of establishing what might 
be a template for how medical schools 
and their affihates can together pre- 
serve the academic mission of medi- 
cine is Michael Rosenblatt '73, the 
Robert H. Ebert Professor of 
Molecular Medicine, chief of the BI 
Division of Bone and Mineral 
Metabolism, and co-director of the 
Harvard-MIT Division of Health 
Sciences and Technology. To his 



already title-laden hat, he has added 
executive director of the Harvard 
Medical School-Beth Israel Health- 
Care Foundation for Research and 
Education, and in that capacity he will 
serve as faculty dean for academic pro- 
grams at HMS and at BI, as senior vice 
president for academic programs. 

"This foundation will help us facili- 
tate the big changes that will have to 
be made in medical education," says 
Rosenblatt. "We're trying to get out 
ahead of the wave so we're positioned 
with a strong academic enterprise." 

Though specifics of the plan are yet 
to be articulated, Rosenblatt has 
announced three immediate steps: 

• establish a state-of-the-art center 
for clinical education for Harvard 
medical students doing rotations at the 
BI in the hospital's new ambulatory 
care center, the Carl J. Shapiro 
Center. It will have a skills area with 
simulators and dummies, carrels with 
computers, teaching programs on CD- 
ROM, digitized teaching files from radi- 
ology, and projection equipment for 
pathology review. 

• start working with the Bl's depart- 
ment heads in all specialties to look at 
ways to bring more clinical education 
into the outpatient setting. Starting 
this July, for example, the core clinical 
curriculum in surgery and medicine 
will expand to include more ambula- 
tory teaching, which at the BI will take 
place largely in the new center. 

• encourage through seed money 
more collaborative research between 
Quad-based and BI faculty — "a lever- 
aged investment" — that could open 
new avenues of research, particularly 
those with the kind of clinical applica- 
bility that will attract outside funding. 

Though education and research 



Spring 1996 



II 



On the Quad 



have been orphaned by reimbursement 
formulas and managed care plans that 
don't support these activities, the new 
foundation is going to try to turn its 
separation from the clinical business 
into a strength. An important part of 
the plan is to attract funding from 
benefactors — individuals, corporations 
and foundations. 

"This money will be used loo per- 
cent for research and education and 
not be blended with the operations of 
clinical service," says Rosenblatt. "As a 
separate organization, the foundation 
will be positioned to promote the aca- 
demic mission." It can raise revenues 
and by being involved in their distrib- 
ution to Harvard faculty and depart- 
ments at BI, influence capital-intensive 
changes such as the redirecting of 
teaching to more ambulatory settings. 

There are about 1 7 other institu- 
tions affiliated with HMS and it is 
hoped that others will do something 
similar. "This is an area where we can 
work collaboratively on medical stu- 
dent education, not competitively the 
way the clinical business has become," 
suggests Rosenblatt. 

Each could have its own foundation 
as a way of teasing out the academic 
component from the hospital's chnical 
business. "The other thing this 
achieves," says Rosenblatt, "is that the 
head of the foundation serves as a 
focused voice of academic medicine in 
that hospital, just as there is a voice of 
surgery, a voice of dermatology, and so 
on." As director of the HMS-BI founda- 
tion, Rosenblatt, for example, sits in 
on key meetings at the BI and at HMS 
"When thinking over changes, I'm 
there to watch out for research and 
education." 

The HMS-BI foundation may itself 
expand if a potential merger of the BI 
with the Deaconess Hospital and its 
Pathway Health Network of suburban 
hospitals — announced at the end of 




Michael Rosenblatt 

February — proceeds. Its network 
includes the New England Baptist, 
Deaconess-Glover, Deaconess- 
Nashoba and the Deaconess-Waltham 
hospitals, which could become 
involved in the foundation as well, 
speculates Rabkin. The Mount Auburn 
Hospital has also joined their merger 
discussions and would add further 
expertise in teaching. 

How the other affiliates decide to 
support education remains to be seen. 
But what the Beth Israel is saying, 
according to Rosenblatt, is: "We all 
have to be concerned with the chnical 
business, but education and research 
are just as important. We're in part- 
nership with Harvard Medical School 
to train physicians for the long haul." 

To do this, Rosenblatt acknowl- 
edges, will take a lot of cooperation 
and collaboration between department 
chairs at the Beth Israel and the med- 
ical school. But big changes take big 
plans. "I have no doubt when histori- 
ans look back, they will see these 
changes in health care as a revolution, 
the biggest thing in probably 100 
years." 

Through creative ways such as this 
foundation to help protect the acade- 
mic mission of its teaching hospitals, 
says Tosteson, "the new foundation 
has the opportunity to restructure and 
restrengthen the educational and 
research programs of the Harvard 
Faculty of Medicine at the Beth Israel 
Hospital and hopefully also at the 
Pathway Health Network and Mount 
Auburn as they move toward merger." 

Ellen Barlow 



At the Juncture of Law and Medicine 

Until now medical students at Harvard 
thought about legal issues only in 
medical ethics or law and medicine 
classes, while law students discussed 
medical issues in health care law 
classes. Though their worlds overlap at 
times, rarely did medical and legal stu- 
dents talk to each other. 

In January 1995 this changed when 
three Harvard medical students joined 
nine Harvard law students to share 
common concerns, interests and ideas 
in a new month-long course entitled 
"Ethical Issues in Clinical Practice: 
Doctors and Lawyers in Dialogue." 
Co-directed by Linda Emanuel '84 of 
the HMS Division of Medical Ethics 
and David Wilkins of Harvard Law 
School, students heard from academics 
and practitioners in both fields on top- 
ics ranging from conflicts of interest to 
the changing relationships between 
professionals and clients. 

We also explored each others' 
backyards — medical students watched 
proceedings in housing court and dis- 
trict court while law students observed 
physicians working in the outpatient 
clinic and the intensive care unit. We 
discovered that the overlap between 
our professions is impressive, and saw 
the value of dialogue between disci- 
plines and the need for continuing 
work and collaboration. 

The presumed antagonism between 
law and medicine, nurtured at times in 
each of our professions by various off- 
hand comments and apocryphal sto- 
ries, was addressed the first day when 
we discussed our reasons for taking the 
course. We discovered much congru- 
ence in how each field confronted spe- 
cific dilemmas, ranging from financial 
conflicts of interest to issues of confi- 
dentiality and truth-telling. These 
ideas formed the basis of many of the 
specific sessions of the course. 

There are, for example, a broad 



Harvard Medical Alumni Bulletin 



range of conflicts of interest common 
to both medicine and law, in which a 
broad view of beneficence is poised 
against personal or financial enrich- 
ment. Perhaps the most obvious cur- 
rent illustration of this in medicine is 
seen in the potential tensions between 
the goals of a managed care organiza- 
tion and a therapeutic physician/ 
patient relationship. In law, the needs 
of the individual client versus the 
needs of the firm form a parallel 
dilemma. 

Another area of concern that cuts 
across both the legal and medical pro- 
fessions is the changing relationships 
between codes of conduct and actual 
practice. In the legal world, the Model 
Rules of Professional Conduct, which 
govern legal practice in a majority of 
states, assert that a lawyer's role 
requires referring to "moral, eco- 
nomic, social and political factors rele- 
vant to the client's situation," as part 
of legal consultation. In medicine, 
codes of behavior fi-om the 
Hippocratic Oath to the American 



Medical Association Code of Ethics 
theoretically inform physicians' ethical 
practice. 

Yet, as practitioners in both fields 
have experienced, the relationship 
between a code of conduct and ideals 
to everyday practice is not always 
clear. Many of us in medicine and law 
have seen the abrupt transition from 
the world of books and theories to the 
world of patients and clients and pro- 
cedures. Attention must be paid to 
making this transition as seamless as 
possible. Medicine tries to do this 
through third and fourth-year rota- 
tions, while law does not have such 
formal and standardized apprentice- 
ships. 

Christine Solt, a 1995 Harvard 
Law School graduate, puts it this way: 
"No one would expect a surgeon to 
perform a complicated procedure 
without at least having observed the 
procedure performed and not based 
only upon prior discussions of the the- 
ory behind the procedure's use. But 
young lawyers are often expected to 



Good Society 

With an eye towards replacing 
antagonism with understand- 
ing, and opposition with coop- 
eration between the fields of 
medicine and law, HMS stu- 
dents Brett Zbar, Akshay Desai 
and Derek Kunimoto, all Class 
of '98, this year launched the 
HMS Law and Medicine 
Society. 

"As our health care delivery 
system continues to evolve, it 
becomes increasingly impor- 
tant for physicians to under- 
stand issues at the expanding 
interface between law and 
medicine," reads an introduc- 
tory letter to first-year stu- 



dents. The society is particu- 
larly interested in how man- 
aged care "may dramatically 
alter the legal context" in 
which physicians make 
treatment decisions, say its 
oi^anizers. 

"Physicians often act with 
inaccurate perceptions about 
what the law is when making 
medical decisions," says Ellen 
Wright Clayton '85, who came 
to medical school after obtain- 
ing a law degree from 
Vanderbilt University and who 
spoke at the society's first 
symposium last year. 

Terri L. Rutter 



draft a contract based upon their abil- 
ity to reason why it might need a par- 
ticular clause, or to balance competing 
theories about the enforceability of 
form contracts." 

Solt's words emphasize what is per- 
haps the paramount issue that links the 
specific areas that we examined in this 
course: the development of the practi- 
tioner and the transition from student 
to professional, whether a lawyer or a 
doctor. This development underlies 
everything else, whether the issue is a 
specific conflict of interest, the process 
of informed consent or any other ethi- 
cal incertitude. 

Our experience in this course made 
it clear to us that future students and 
practitioners in law and medicine will 
benefit from cross-disciplinary educa- 
tion and interactions. We believe this 
effort should be undertaken as a com- 
plement to courses in ethics and pro- 
fessionalism within each discipline and 
then continued throughout training in 
the professions, maybe even involving 
continuing education courses. The 
critical properties such training must 
have are the continued exchange of 
experiences and ideas, the recognition 
of areas of common purpose and 
shared values and, perhaps most 
importantly, the correction of the 
myopia that can so easily arise in both 
fields. 

Joshua Hauser 'py and 

Paul TK Cheng 'py. 



Spring 1996 



13 



The Next 
Generation 



by Robert A. Greenes 



http://anyinfo.anywhere.4.u 

At work, at home, at play, there 
is no escaping it. The Web is every- 
where (note the capital "W" distin- 
guishing the Web from an ordinary 
web, as spun by a spider, woven by a 
mystery writer, or making up a fish 
net). In the remote possibility that 
there exists a reader who does not 
know what the Web is, I am referring 
to the World Wide Web (or WWW), 
the phenomenon that has popularized 
the Internet and put the information 
superhighway within reach of anyone 
with a computer and a modem. 

Wherever you turn — the newspa- 
per, TV, radio, billboards, magazines — 
you are bombarded with those 
"http://" Web addresses to let you find 
the Thai restaurant nearest you, exam- 
ine your stock portfolio, learn about 
new cars, check out local real estate 
offerings, or even learn the capital of 
Tanzania. Moreover, as Americans and 
citizens of the planet flock to this new 
"place" to be, and more people learn 
how to put their own information on 
the Web, it will be hard to hold out 
against being there yourself. 

It is tempting to dismiss the Web as 
simply a way to occasionally look up 
something useful, like the weather or 
airline schedule, or the progress of 
your Federal Express package. 
Helpful, but hardly earthshaking, since 
this same information could be gained 
in many other ways — even something 
as retro as a telephone call — which 
don't require you to be plugged into a 



laptop with a modem or network card! 

It may be easy to say that most of 
this is unedited, unfiltered piffle, the 
magnitude of which will only get 
worse and overwhelm us all, as every- 
one has his or her own "home page" 
professing to be experts on something. 
With the growing cyberglut, how will 
we be able to distinguish the occa- 
sional truly useful morsel of informa- 
tion from the tons of inane stuff, the 
edited from the unedited, the 1 helpful 
response fi-om the 458 frivolous or 
outright incorrect items retrieved in 
response to a query? We are beginning 
to fall victim to a malady of the 
nineties — neurotica informatica or 
"information anxiety." 

The World Wide Web may seem a 
curiosity to some, an object of hype to 
many, even a danger to others. These 
characterizations fail to recognize its 
essential impact on the future of how 
we live and work, perhaps nowhere as 
notably as in health care. Physicians 
are only scarcely aware of the pro- 
found effect this phenomenon is hav- 
ing on our profession — by facilitating 
the transformation of our health care 
system into a new one. 

The nature of the transformation in 
health care is from a system dominated 
by monolithic institutions and prac- 
tices and independent providers to one 
in which highly federated enterprises 
are emerging, in an attempt to cope 
with growing pressures on cost while 
maintaining cost-effectiveness and 
quality. Curiously, the information 



technology industry is undergoing a 
similar transformation from mono- 
lithic and independent software to 
applications based on highly federated 
components. The Web is a metaphor 
for such new software approaches. I 
will try to show how these two seem- 
ingly separate but parallel processes 
relate to one another and, in fact, how 
the changes in the health care system 
are being enabled by federated soft- 
ware. 

The Web as metaphor 

The Web is an example of a set of 
related developments that radically 
differ from most computer software 
you have used before. Because of its 
pervasiveness, the Web is not only an 
example but an apt metaphor for this 
group of developments. 

The capabihties of the Web are a 
result of the confluence of powerful 
multimedia graphics-capable comput- 
ers, high speed networking, and soft- 
ware that is able to access and utilize 
information in distributed, often far- 
flung locations. The Web is not itself a 
computer program but a set of rules or 
conventions by which messages can be 
sent from one computer to another 
and be understood. Web "applica- 
tions" are simply collections of docu- 
ments, connected through "hypertext 
links," pathways to other information. 

The documents of a Web appUca- 
tion are put together for a specific pur- 
pose, such as a New York Times 
summary of current articles, a weather 
map with detailed forecasts available 
for individual locations, or a collection 
of clinical guidelines together with 
explanatory notes and references. 
These documents are accessed and dis- 
played on your PC (I use this term to 
refer to both IBM-compatible and 
Macintosh personal computers) by a 
program called a Web "browser" (a 
number of these exist, the most famil- 
iar being Netscape and Mosaic). 
Documents may contain a set of desig- 
nated phrases, icons, or other design 
elements which serve as pointers 
(links) to other documents, which may 



14 



Harvard Medical Alumni Bulletin 



be stored on different computers or all 
on the same computer. 

A Web application is unlike the 
typical self-contained application that 
you probably bought to do word pro- 
cessing, spreadsheet calculations, or 
slide presentations, and even more 
unlike the integrated packages that do 
all of these together (so-called "office 
suites"). These traditional programs 
are self-contained and barely use a net- 
work, except perhaps to share a printer 
or to store files in a common shared 
disk. The Web is also very different 
fi-om the information systems used in 
typical health care institutions, which 
may also utilize networks, in that those 
systems are typically highly integrated 
packages, running on one or more 
large central computers, to which ter- 
minals or workstations may attach and 
send and receive information. 



A regional medical network's home page, in which 
Patient Data has been selected. 



The Web differs from both of 
these models in that its applications 
rely intensively on the network for all 
of its information. The only require- 
ment is that the computers containing 
the information be connected to the 
Internet and have Web server software 
that allows them to communicate in 
the standard Web-compatible format. 

Extensions to the Web model have 
occurred. For example, the Web 
browser you can run on your home or 
office computer is designed to retrieve 
information from network-connected 
computers in the form of documents — 
yet this need not be limited to "static," 
previously created documents. A Web 
browser can be used for querying data- 
bases, with the results of the query 
shown in a displayed document; how- 
ever, in this case, the document is not 
static but is generated dynamically by 
the remote computer that has searched 
the database. The source could be a 



patient database, a Medline journal 
database, or a clinical guideline reposi- 
tory. 

Other extensions to the Web 
browser allow you to enter informa- 
tion, not just retrieve it. This could be 
as simple as entering a query term for 
a literature search, or selecting a movie 
for which you want to retrieve a 
review, but it can also include filling 
out rather detailed forms, for example, 
for ordering a product, registering for 
a meeting, describing a patient's physi- 
cal findings, or entering discharge 
orders. This information, once col- 
lected, is sent by the browser to a dis- 
tant computer for processing or 
storage in its database. A "browser" is 
thus sort of a misnomer for the pro- 
gram used to traverse the Web, since it 
is not only used for retrieving informa- 
tion but can also function as a "trans- 
action processing" interface for 
carrying out various activities — like 



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Spring 1996 



15 



pa Dent care! 

\\^eb-like capabilities are extended 
further with small application pro- 
grams known as "applets." One such 
approach uses a language known as 
Java (developed this past year by Sun 
Microsystems Inc. and already sup- 
ported by many hardware and software 
companies) to write applets that can 
run on essentially all common models 
of PCs. The impact of this is signifi- 
cant. 

Consider your word processor, a 
single behemoth of a program chock 
full of features you may never use. 
Such "bloatware" could be replaced by 
a very small Java program for text edit- 
ing. When you want to do a spelling 
check, an applet for this is brought 
over the network. To do equation 
editing, yet another applet is brought 
over, and similarly for other functions 
such as mailing list merging, inclusion 
of a spreadsheet table, or incorpora- 
tion of a drawing. A clinical worksta- 

A guideline for seizure workup and management witli a 
patli liigliliglited su^esting referral to a neurologist. 



tion apphcation could be implemented 
with Java in such a way that lists of 
laboratory values could be retrieved 
from an electronic record system, for 
example, and plotted graphically, or a 
radiologic image could be displayed 
and its brightness and contrast manip- 
ulated, or rotation of 3-D images 
could be done. 

Some major computer companies 
have gone so far as to develop basic 
"Internet machines" — available within 
a year — in which standard software 
packages and disk storage on your PC 
will be unnecessary, since the Internet 
will be both the source of all needed 
software applets and also will be able 
to store and retrieve your files for you. 

The Web and extensions are exam- 
ples of several technology develop- 
ments enabling the Internet to be used 
to link together information 
resources — documents, databases and 
application modules — housed on sepa- 
rate computers. The Web is, by virtue 
of its popularity, a major method for 
accomplishing this. But other 



approaches aim to integrate visual 
objects on your computer screen (such 
as buttons, menus, lists, images, text 
elements, drawings and charts) in flexi- 
ble ways such that these visual objects 
are actually produced and controlled 
by remote software components on 
other computers. This means that the 
application you are running on your 
computer is like the conductor of a 
musical score, indicating what ele- 
ments should be played by what 
orchestra member at what time, but 
the actual responsibility for doing 
these things is not in the application 
but resides with the orchestra member. 

Again, a clinical workstation appli- 
cation is one such example, where a 
visual display of a medical chart with 
divider tabs could be used to page to 
specific sections, where the informa- 
tion contained is actually retrieved 
from other connected computers. 
Forms for entry of new findings or 
links to expert systems producing 
advice about likely clinical problems 
based on the displayed information 



Information 




Guideline State 
Map 




New Onset Seizures 



Assess 
Consciousness 



~Zj 



xv 



Not Impaired 



xT 



Impaired 



Consider Simple 
Partial Sz 




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Blzzare 
Episodes 



Headache 
Present 



Consider 
Migraine 




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16 



Harvard Medical Alumni Bulletin 



could also be visually incorporated. 

The information technology indus- 
try has been turned on its head. 
Prominent solitary applications for 
personal computers are soon to be 
replaced by, or at least have competi- 
tion from, apphcations made up of 
federations of network-distributed 
components. Major applications for 
business, including health care sys- 
tems, will go through a similar trans- ^ 
formation; in health care, patient data, 
clinical images, guidelines, decision 
support modules, educational 
resources, and e-mail/communication 
tools will soon no longer need to be 
integrated into single institutional sys- 
tems, but will be woven together from 
disparate components. 

A "Lego block" approach 

The technology I have described is 
based on the notion that it is a good 
idea to build applications by identify- 
ing individual, useful tasks, building 
separate components that accomplish 
those tasks, and then integrating the 
components in specific ways to create 
unique applications. This "Lego 
block" approach has a number of 
implications for health care informa- 
tion systems. 

First, in an effort to find a market 
niche, component producers can be 
expected to strive competitively for the 
best components for clinical data 
access, image processing, diagnostic 
expert system, Medline retrieval, 
form-based data entry, voice recogni- 
tion, or guideline display. Databases of 
drug information, laboratory reference 
values, and national or international 
pooled clinical trial results will all seek 
to be accessible, authoritative, up-to- 
date and complete. 

Second, applications — that is, pro- 
grams that integrate components — can 
be customized, adapted to the require- 
ments of the user. It will be relatively 
easy to develop specific programs for 
nurses, physicians, medical students, 
educators, researchers and managers. 
Programs can also be further adapted 
for specific purposes and preferences. 



e.g., whether you want to examine 
patient data in chronological order, 
according to source (progress notes vs. 
labs vs. radiology), or by problem; and 
how you want to input data (by voice, 
pen, mouse or keyboard) and output it 
(tabular, narrative or graphic). 

Third, re-use of the same compo- 
nents will be possible in different 
applications. The same image process- 
ing tools could be used in a student 
workstation application or in one for a 
practicing radiologist. The same data- 
base — e.g., patient data, Medline or 
drug reference — could be used by a 
primary care physician or a cardiac 
surgeon, but organized in a different 
format, according to the way that per- 
son's workflow is carried out. 

Finally, "extensibility" is relatively 
easy. New components can be inte- 
grated into applications, or the appli- 
cation can be updated to provide new 
ways of accessing components. 

There's a Web in Your Future 

Web-based applications are beginning 
to find their way into health care sys- 
tems. Columbia Presbyterian Medical 
Center in New York is using the Web 
as a means for accessing patient data. 
The Web's primary role is as a "front 
end" (a visual, graphic front end that 

The clinical profile of one of the available neurologists, 
who has a clinical interest in seizures and speaks Spanish. 



can run on virtually any kind of com- 
puter) to a variety of existing "legacy" 
systems that currently maintain 
administrative and demographic data 
for patients, laboratory, x-ray, pathol- 
ogy and other results. 

A major concern here, of course, is 
security and protection of privacy of 
data such as a patient's clinical record. 
The software industry is developing 
technological approaches to this, as the 
health care industry is seeking to 
develop policy and procedure for 
determining access privileges and 
authentication of users. 

At Partners HealthCare Systems, 
we are using the Web as a means for 
supporting a developing regional net- 
work of patients and providers. The 
Web will serve as the interface for 
access to information about the various 
heath care institutions in the regional 
network, including the Brigham and 
MGH, the departments and their ser- 
vices, the participating physicians, 
upcoming seminars and other events. 
Primary care physicians will be able to 
obtain problem-specific guidelines and 
other educational resources, enter data 
and send messages. Patient data will be 
accessed via this method or another 
network approach, based on security 
considerations still being evaluated. 
However, in this environment, both 
patients and providers will use the 



Brian RysLn^ MD 




Phone: 


(617)522-4700 


■» 


Fax: 


(617) 983-0434 


^ 


Inteniet Ad&iess : 


iyafl@umversity.edu 




Languages: 


Hebrew, Spajnish 


' 


MD Degree: 


Temple University School of 
Medicine 


1989 ' "' 


Residency: 


University of Pittsbutgh 
fjHsiJis/MedJiznii! _ 


1992 


Fello-vsMp: 


University of Medicine and Dentistry 
of Nev Jersej' 


1993 




Brigham and Women's Hospital 


1995 


Board 
Ceitifications: 


Nenmlf^y 


1993 


Clinical Interests 






Seizure Disorders 






S 


PRING 1996 


17 



^^"eb as a primary means of communi- 
cation, information access, education 
and decision support. 

Furdier evolution of diese 
approaches is not hard to foresee. 
Current dedicated systems for specific 
functions — such as patient data access, 
chnical image review, guideHne or 
educational reference, MEDLINE 
search, decision support, e-mail com- 
munication and practice manage- 
ment — will either be replaced or 
function as "back end" data sources 
and processing engines for a set of 
applications based on the Web, Java 
and other component/integration 
technologies. We will have new appH- 
cations that provide access to all the 
tasks necessary for our daily work via a 
single, consistent user interface. 

Emei^ence of new health care enterprises 

Changes in our health care system are 
necessitating that we all use comput- 
ers. New forms of health care enter- 
prises are developing: regional health 
care networks are now tying together 
patients, primary care, community 
hospitals, tertiary medical centers, and 
a variety of other supporting services. 
These are blurring previous institu- 
tional boundaries and making the 
"brick and mortar" of institutional 
walls less meaningful. To become effi- 
cient, certain services such as radiology 



An e-mail message to the consultant with a summary of 
the workup. 



Send New | Quote | Attach | Address | Stop 

Subject : |New referral 



and pathology have begun to seek ver- 
tical market niches on a national or 
even international scale through tel- 
eradiology and telepathology systems, 
further loosening geographic and 
institutional constraints. Multi-institu- 
tion health care chains are now seeking 
efficiency by incorporating services, 
such as imaging, which may be geo- 
graphically remote from where they 
are used. This is resulting in new 
alliances. 

As the health care system trans- 
forms from independent, separate 
providers to a new system relying on 
federations of providers and services, 
former individual providers are being 
looked at as components — e.g., a radi- 
ology group, a clinical laboratory, or a 
neurosurgical service — which must 
compete to be part of new enterprises. 
The enterprises are integrating these 
components in various ways. Health 
care is becoming a cooperative activity 
in which the patients, physicians, 
health care institutions and other 
resources must share information and 
operate more cost effectively. 

The information needs for such 
cooperation grow dramatically as the 
complexity increases. In the midst of 
such enterprise change, existing insti- 
tution-based and free-standing infor- 
mation systems will be relatively 
difficult to adapt to the new require- 
ments. It is curious that both health 
care and the information technology 




'^ Addressing 



Attachments 



Mail To: ryan@university.edij 
Co: 



Dr. Ryan, 

I would like to refer my patient. Rich Fernandez. 

He is a 48 year-old hispanic gentleman with a 

diagnosis of new onset seizure disorder, probably 

complex partial in nature. The referral guideline 

suggested that I consult a neurologist for further 

workup. 



/\ 



a 



industry are going through similar 
transformations at the same time. Both 
are in the midst of breaking up into 
components that can compete in the 
marketplace based on cost and quafity, 
and of integration to deliver new com- 
binations of capabilities. 

To be sure, the genesis of the 
transformation in health care is differ- 
ent from that occurring in the infor- 
mation technology industry; it has 
been brought about by a cost crisis 
that has driven major changes in 
financing mechanisms. The changes in 
information technology have in a sense 
been more self-evolving as a kind of 
"technology imperative," developing 
out of trends in object-oriented soft- 
ware methodology, workstation pro- 
cessing capability, high-speed 
networking, and the emergence of 
protocols and standards for communi- 
cation and message-passing. 

The changes in the health care sys- 
tem are increasingly dependent on 
information technology. It is now 
likely, even inevitable, that much of 
our health care will be conducted over 
interactive networks, whether they be 
communication between a patient 
through his home television set and a 
doctor in her office, between a doctor ■ 

and a specialist, between a consulting 
surgeon guiding or even performing a 
remote procedure and others on-site, 
or among a team of doctors in consul- ^ 

tation using an on-line decision aid. ^ 

Robotics and remote sensors, trans- 
mission of sound, images, and motion 
video, and integration of decision aids 
are loosening the dependence on phys- 
ical proximity just as our health care 
institutions are seeking ways of refor- 
mulating themselves to be more cost- 
effective and competitive, while 
maintaining quality. They are also 
striving to differentiate themselves 
from their competitors by offering 
wider ranges of capabilities and added 
value. 

An oi^anizing paradigm 

A major additional element that will 
occur in health care is the integration 



Harvard Medical Alumni Bulletin 




A video message back from the consultant, with results 
of a SPECT study showing abnormal seizure activity. 

of guidelines for clinical practice. This 
integration will happen largely 
dirough information technology. A 
guideline can be a tool for education 
and training, for reference in a prob- 
lem solving situation, for audit and 
monitoring, for detecting untoward 
events, or for fostering improved 
workflow. 

Although cUnical practice guide- 
lines are often looked at by physicians 
as unwelcome constraints on patient 
care, they may well become primary 
organizing tools for health care infor- 
mation access. Consider the growing 
dependence on guidelines in our 
health care organizations, not only for 
clinical decision making, but for 
prospective approval, claims review, 
utilization review and quality assur- 
ance, and education. Rather than being 
bothersome impediments, guidelines 
can serve in new systems by organizing 
workflow and anticipating information 
needs. 

Imagine that you are a primary care 
doctor seeing a patient with a problem 
of persistent dizziness, which you have 
worked up and believe to be of neuro- 
logical origin. Even if not highly spe- 
cific, a guideline may help you not 
only in the specific workup and man- 
agement, but in providing an organiz- 
ing method and access point for a 



variety of problem-specific resources 
you may need. For instance, once you 
have pinpointed the place in the 
guideline (a clinical state) that pertains 
to the patient, links can be made auto- 
matically by computer from this clini- 
cal state to an information tool that 
retrieves specific stored clinical data 
pertinent to this state; to another tool 
that displays a form indicating data 
usefiil to collect; to another suggesting 
various actions that can be ordered — 
with links to references detailing the 
circumstances in which these are most 
appropriate; to another that provides a 
list of specialists in the health care plan 
who have expertise in this area, 
together with their resumes, photo- 
graph and e-mail address; to a variety 
of other decision aids and educational 
resources, and so on. 

Further, if you decide at this point 
that the patient needs an MRI scan, a 
document describing this process 
could be downloaded and given to the 
patient (or the patient can access the 
information from home via its Web 
address), along with driving and park- 
ing directions to the MRI facility. If the 
patient is to undergo a surgical proce- 
dure, information on the operation, 
expected post-operative symptoms, 
stored interviews with previous 
patients answering frequently asked 



questions, and other material can be 
given to the patient. 

Elements of the long-term goal for 
enterprise information support are 
finding their way into our Web-based 
developments for Partners HealthCare 
System. The Web and related capabil- 
ities are very enabling, since new 
providers, services and clients are rela- 
tively easy to integrate into the system. 

My primary message is that our 
approach to the health care system 
needs to be flexible, as we adapt our 
institutional and professional relation- 
ships to the reahties of cost contain- 
ment and the need for systemic 
cost-effectiveness and quality. These 
new realities mean that sometimes 
locally suboptimal practices (e.g., less 
patient volume for a service) may be 
optimal from the perspective of the 
patient's care. Time and place are less 
likely to be barriers in the future. As 
specialists we may provide consulta- 
tion about unseen patients, and as pri- 
mary care physicians we may deal with 
far-flung specialists and ancillary ser- 
vices. We will also heavily use infor- 
mation resources, and workflow and 
guideline tools will always be at hand. 

This means that we all need to 
understand our potential roles in this 
new federated world. We must under- 
stand the information needs that have 
to be communicated and the informa- 
tion resources and tools that can help 
us. Cyberspace has met health care and 
the system will not be the same. 

The usefulness of what we forge is 
up to us. Well chosen component ser- 
vices, sensible methods of integration, 
empirically based guidelines, and reli- 
able information support are what we 
must seek. ^ 

Robert A. Greenes, MD '66, PhD, is HMS 
associate professor of radiology and director 
of the Decision Systems Group at the 
Brigham and Women 's Hospital. 



Spring 1996 



19 



Medicine On-Line 



by Jerome P. Kassirer 



About a year ago Partners 
HealthCare President Sam Thier was 
asked to speak about how he thought 
medical care would be delivered in the 
twenty-first century. He began by 
explaining that the pace of change in 
the delivery of medical care was so fast 
that he wasn't even sure what it would 
be like when he returned to his office 
that very afternoon. He was only half 
joking. Hospitals are rapidly losing 
their dominance in health care deliv- 
ery; physicians are no longer the prin- 
cipal decision-makers; industrial-size 
health care networks built around 
managed care plans that enroll large 
numbers of people are flourishing; and 
a few giant insurance companies influ- 
ence the kind of health care that is 
being provided. 

These profound changes in the 
delivery of care cloud our vision of the 
future, yet three subtle trends are sur- 
facing that are likely to have an enor- 
mous influence on the delivery of 
health care in the next century. I refer 
here to the rapid growth of computer- 
based electronic communication, the 
familiarity of a new generation with 
this kind of information transfer, and 
the shift toward giving patients more 
responsibility for decisions about their 
health care. These trends may well 
lead to cultural changes in the delivery 
of health care that are even more revo- 
lutionary than its current restructur- 
ing. 

At some future time, I believe, on- 
line searches of databases will produce 
a better informed public and com- 
puter-assisted communication between 
patients and physicians will replace a 
substantial amount of the care now 
delivered in person. 



Many people already own personal 
computers and use them in their stud- 
ies or business activities, and many are 
using the Internet to communicate 
with colleagues, friends and family 
members. Over the past few years, the 
Internet has grown remarkably. The 
number of users is somewhere in the 
range of 7 miflion to 30 million, and 
many new networks are being added 
daily. New software tools, including 
free client-server programs, are mak- 
ing the computer files, bulletin boards. 
World Wide Web pages and news- 
groups on the Internet more accessible 
and easier to find. Companies such as 
America Online, CompuServe and 
Prodigy offer menu-driven search and 
e-mail packages that are simple to use 
and relatively inexpensive. 

At the same time, technology is 
catching up. "Smart boxes" and "smart 
television sets," which combine the 
functions of the computer, telephone, 
fax machine, compact-disc player and 
television will simplify electronic com- 
munication even more. The wide- 
spread extension of fiberoptic and 
coaxial cable communication across 
the country will speed up the transmis- 
sion of all types of digital signals. 
Finally, the concomitant increase in 
patients' willingness to take more 
responsibility for their own medical 
care will have an important impact on 
the use of the Internet for medical 



care. 



At present, the medical information 
available on-line for the public is lim- 
ited, yet commercial services already 
provide "textbook" information that is 
comprehensible to an intelligent 
laj^erson; and on-line discussion 
groups about topics such as diabetes. 



eating disorders and vitamins are 
growing. The problem is that much of 
the information conveyed in these 
forums is of questionable parentage 
and doubtful validity. Some medical 
centers, however, are hosting their 
own on-line discussions, to which pro- 
fessionals from that center contribute 
information. Industry is sure to follow. 

How could care be provided on- 
line? In principle, responsibility for 
decisions could be shared by the 
patient and the physician. The patient 
could search for information in 
authoritative medical databases pre- 
pared for lay audiences. Common 
problems such as urinary and upper 
respiratory infections could be handled 
by the patients themselves with the aid 
of on-line algorithms. Even some 
complex clinical problems could be 
handled by an on-line consultation 
with a physician. 

Changes in the dosage of insulin, 
anticoagulants, antihypertensive drugs 
or diuretics, the management of many 
childhood diarrheas, and decisions 
about when to give tetanus boosters 
and when during labor a woman 
should go to the birthing center are 
but a few examples. Standard 
reminders for many routine screening 
tests or vaccinations could be sent 
electronically. Chances are that many 
people will be quite comfortable with 
this kind of interaction. Imagine: a 
new kind of house call by a "virtual 
physician!" 

Although a health care delivery sys- 
tem that depends, even partly, on on- 
line communications holds 
considerable promise, the problems it 
poses are enormous. Familiar issues 
such as the continuity of care, the 



Harvard Medical Alumni Bulletin 



validity and consistency of the avail- 
able information, privacy and effects 
on the physician/patient relationship 
will all surface as major areas of con- 
cern. Axi even greater concern is the 
possibility that an electronic form of 
medical care will be introduced for the 
principal purpose of cost savings and 
that it will circumvent physician 
involvement and jdeld inferior quality 
of patient care. 

There are many practical limita- 
tions to an on-line system of health 
care delivery. Despite the recent 
expansion of on-line communication, 
we do not know whether tJie public 
will accept this kind of medical consul- 
tation, or whether improvements in 
science education will increase the 
public's ability to understand medical 
information. Issues such as ease of use 
will have to be addressed; undoubtedly 
many people will lag behind in taking 
advantage of any kind of on-line infor- 
mation, and some will never use it. 

People who do so are likely to be 
barraged with conflicting reports, var- 
ied opinions and contradictory recom- 
mendations. We will have to learn 
what kinds of medical problems can be 
safely and effectively handled by physi- 
cians who are remote from their 
patients. And a new conflict will 
emerge: some mechanism will be 
needed to foster the appropriate 
acceptance of responsibility by patients 
for their care while providing protec- 
tion against dangerous self-diagnosis 
and self-treatment. 

Some people will object to receiv- 
ing some of their care by computer. 
They will still want to hear a human 
voice on the telephone, even though it 
may take hours to make contact with a 
physician. No doubt something 
important will be lost if physicians no 
longer see patients in person for every- 
day problems: the "laying on of hands" 
does have therapeutic value. 
Maintaining the confidentiality of sen- 
sitive, personal information is still 
another extremely important issue. 
Nobody but the patient and his or her 
physician should know, for example. 



Imagine a new kind 
of house call by a 
''virtual physician! " 



that the problem is blood in the stool 
or sexual dysfunction. 

Affordability will become an issue if 
the government stops supporting the 
Internet. Companies such as America 
Online and CompuServe will certainly 
offer many more services, but they will 
charge, and whether the free services 
offered by universities will be contin- 
ued is yet to be determined. Because 
the cost of the new technology will 
further widen the gulf between those 
who have access to care and those who 
do not (or at least exaggerate the dif- 
ference in the quality of care between 
the two groups), it will be critical to 
find a way to protect and treat those 
who are unable to use or pay for an 
on-line system. 

Widely implemented on-line sys- 
tems would have a profound effect on 
those who provide health care. 
Integrated networks for the delivery of 
medical care will have methods of 
tracking the care provided and the 
costs of that care and the same system 
could be used in an electronic network 
to communicate with patients. 
Physicians would be expected to inter- 
pret much more information in that 
case but they, too, would have access 
to far more up-to-date data. 

Establishing credentials, licensure 
and the definition of malpractice will 
take new forms when medical advice 
and decisions are transmitted by a 
communications medium that crosses 
state and national boundaries. The 
nature of a patient's medical record 
will also change. Inevitably, an elec- 
tronic data repository will be devel- 
oped for each patient, but deciding 
what form it will take and which insti- 
tution or entity should be responsible 
for maintaining it will require consid- 



erable attention. If much health care is 
handled on-line, personal encounters 
will focus principally on the most seri- 
ous problems. In that case, we might 
need even fewer primary care physi- 
cians, nurse practitioners and special- 
ists than the numbers predicted today. 
We must not ignore these remark- 
able trends and prospects. Although it 
is easy to identify what might go 
wrong in delivering medical care on 
the Internet, there are cogent reasons 
to believe that on-line medical com- 
munication also provides important 
opportunities. Better informed 
patients, more efficient use of 
resources, and enhanced communica- 
tion between doctors and patients are 
possible outcomes. For the benefit of 
our patients, physicians should be at 
the forefront of these changes, not 
dragged along by progress. ^ 

Jerome P. Kassirer is editor-in-chief of 
The New England Journal of 
Medicine and HMS lecturer on medicine. 



Spring 1996 



Solitaire 
Confinement 



by William I. Bennett 




My slide into abject addiction 
began when I bought a new PC. The 
previous one was a serviceable laptop, 
six or seven years old, with a slight 
wheeze, a slow chip, and a blue-gray 
screen. The new one, purchased last 
summer, is already a little quaint but 
at the time was edging toward the 
high end of the market for home or 
small-office equipment; it came with a 
fast chip and vast memory, a CD-ROM 
drive, and speakers resembling the 
eyes of a highly-evolved insect pre- 
pared to exsanguinate me. 

My fantasy, of course, was that my 
productivity would increase in propor- 
tion to the enhanced firepower of this 
new gadgetry. Not only would I know 
how Prozac interacts with drugs from 
gold salts to melatonin, I would be 
able to generate road maps for every 
Springfield in America and recall every 
Avercamp, Boticelli, Crivelli, and 
Delacroix in the National Gallery. At 
the very least, I should be able to get 
my bills out on time. 




In the event, it was the telephone 
book on CD-ROM that tripped me up — 
not the program itself, but the fact that 
its 85 million U.S. listings on half a 
dozen disks all formed an elaborate 
shell encasing an innocuous-seeming, 
but for me virulent, agent directly 
attacking brain tissue. A computer 
game packaged with the utilitarian 
directory — and one of the least elabo- 
rate, least interesting of the lot — was 
my downfall. 

Virus protection was something I 
knew about and was prepared for. 
What I did not anticipate was that my 
self-image as Cortez gazing from a 
peak in Darien at the boundless riches 
of Silicon Valley would expose me all 
but fatally to a foreign disease against 
which I had virtually no immunity. In 
sum, a version of solitaire came to 
dominate my life for nearly six months 
and still, if I let my guard down for a 
moment, renders me paralyzed for 
hours afterward. Nothing in my earlier 
experience predicted this. 

Since childhood, I have had little 
interest in games, brain-twisters, or 
puzzles of any kind. Three college 
roommates devoted to bridge quickly 
discovered that I gave new depth to 
the term "dummy." In the past 40 
years I have attempted the Times's 
crossword puzzle perhaps half a dozen 
times and have never completed it. I 
have, in my time, read countless mys- 
tery stories, and without exception 
have not guessed the murderer until 
several pages after his or her identity 
has been explicitly revealed by the nar- 
rator. I did fall in with dubious com- 
pany for a while in my late 30s and as a 
result acquired a passing taste and a 
very limited talent for pinball. Unable 
to convert to Pac-Man and its descen- 
dants, I have not dropped a quarter 
into anything but a parking meter or a 
washing machine for over a decade. 

I am not proud of this aspect of my 
personality. I firmly believe that cre- 
ative people in most fields must be 
active puzzle and game fans. A good 
game provides structure while induc- 
ing fantasy, free association, and 



bloodthirsty competitiveness — the 
same traits that yield poems, theorems, 
musical compositions or scientific 
hypotheses. Something about my 
inability to become engaged in a game 
betrays an unpleasant truth about my 
mind, a crucial defect in my capacity 
for curiosity, or at least in the range of 
things about which I'm able to be curi- 
ous. 

This blunting of intellect should 
confer at least some protection from 
the dark side of game playing: the 
mindless waste of time. Not so. The 
mindless part seems to be what has 
hooked me. 

How did this game penetrate my 
habitual defense of apathy? I can only 
guess. Unlike the standard version of 
solitaire, which in computer form 
comes packaged vdth Windows, 
FreeCell solitaire begins with every 
card face up. The challenge is to move 
cards around according to certain rules 
until they're all piled up by suit. The 
purveyor of this "logic puzzle" makes 
two claims for it: (i) "there is no luck 
involved after the initial shuffle" and 
(2) "it is believed (although not 
proven) that every game is winnable." 
If both propositions were true, the 
game would be a two-dimensional ver- 
sion of Rubik's cube (another in the 
long list of games that I have been 
unable to tolerate for more than 
nanoseconds at a time). 

The first assertion is in a trivial way 
false because, as the computer version 
of the game is designed, the two red 
and two black aces cannot always be 
distinguished from each other at the 
beginning of the game; thus, the 
player may have to make many moves 
with no hope of predicting their con- 
sequences. It is my hunch that the sec- 
ond and more fundamental 
proposition is also false, but the easiest 
way to demonstrate this would be to 
find a deal in which no card after the 
first four can be moved, and there 
appears to be no such hand. This 
leaves the more daunting task of prov- 
ing that at least one of the 52! possible 
deals cannot be won. 



Spring 1996 



23 



The software offers only 32,000 of 
these deals, and by now I've played a 
frighteningly large fraction of them, 
losing" about half. This is a truly dismal 
fact of my current existence. 
Unfortunately, the people closest to 
me have behaved in thoroughly co- 
dependent ways, murmuring empathic 
remarks that only enable me. 

"Of course, you're tired at the end 
of a long day working so intensely with 
people's emotions. Why wouldn't you 
want to relax with a nonverbal game?" 
Here's why: I'm only really good at 
this game when I'm in peak mental 
and physical condition. Playing it at 
the end of the day is a considerable 
waste of time. Playing it when I can 
meet the challenge (say 9 o'clock in 
the morning) is an utterly devastating 
waste of time. 

"Well, at least this is one place in 
your life where you can put things in 
order." Yeah. Except that in the hours 
I've spent trying to maneuver a black 
jack onto a red queen I could have 
filed a lot of reprints and done my 
taxes. 

How did I wind up in this abyss? 
Why couldn't I at least play the elec- 
tronic chess game that also came with 
the computer? I can answer the second 
question. The chess program reHably 
humiliates me and usually within ten 
moves. Wirming solitaire about half 
the time seems to be the optimal 
schedule of reinforcement — not too 
frustrating for this pigeon and not so 
easy as to be meaningless. 

Moreover, winning proves not to 
be the only reinforcement. I have 
found that if I play the game long 
enough, I start to hallucinate. It hap- 
pened first when I was recovering 
from a brief febrile illness and played 
for several hours straight. After a 
while, I started to hear a voice. The 
words were indistinct, but the accent 
was clearly Irish. Subsequently, I have 
heard several regional British or 
American accents and, occasionally, 
French-accented English. The speaker 
may be either male or female, and the 
sensation is always utterly pleasant. As 



time has gone by, the voices have 
appeared after ever shorter intervals 
of playing the game, although I must 
be alone in the house with no music 
playing in the background. The temp- 
tation to achieve this state of mind is 
often considerable, as I have not 
experienced it in any other way. 
(Strictly speaking, this is a form of 
dissociation, but I prefer to think of 
it as hallucinating.) 

I doubt whether I would ever have 
become hooked on this game — or 
experienced the hallucinogenic 
effect — if I had to play it with physical 
cards. The computer allows the expe- 
rience to become as nearly a disem- 
bodied act of nonverbal thought as it 
could be. Only the slightest movement 
of a mouse held comfortably in my 
right hand is necessary. The program 
makes the physical moves for all prac- 
tical purposes at the speed of light; it 
cheerfully infers that I want to move a 
stack of cards exactly when I do want 
to; and the instant a win becomes 
inevitable, it scoops all remaining 
cards from the virtual board to the vir- 
tual winning piles. 

Illuminating as all this has proved 
to be about my own psychology — 
demonstrating so clearly that my 
Achilles tendon inserts directly into 
my brain — it also says something 
about America. I know a lot of other 
computer owners with a guilty secret 
very similar to mine. Unfortunately, I 
think we will never be able to form 
Computer Games Anonymous, for the 
simple reason that it's much easier to 
be anonymous in person than through 
the Internet. So I venture to say that 
what this country needs at least as 
badly as the V-chip is a G-chip, which 
can ruthlessly scan hard disks for 
games that seduce even the sturdiest 
and most productive of the remaining 
Puritans. ^ 

William Ira Bennett '68 is HMS instructor 
in psychiatry at Cambridge Hospital and 
editor-in-chief of the Alumni Bulletin. 



The Giant Brainstorm 

He started out with two potatoes for thai- 
ami and a bowl for a cortex. Then three 
years ago Majid Fotuhi '97 devised two 
five-foot-tall models of the brain to use as 
a teaching aid. But now Fotuhi's vision has 
appreciably grown: he would like to build a 
five-story-high "Giant Brain" pavilion that 
the public could walk into and — through 
hands-on games, virtual reality and interac- 
tive CD-ROM programs— learn such things 
as how vision works, how drugs change 
moods, and how memories are formed. 

But the idea started with a simple spud. 
Teaching while pursuing his doctorate in 
neurosciences at Johns Hopkins, Fotuhi 
yearned for a three-dimensional model 
that could help medical students strug- 
gling with neuroanatomy. Pictures in text- 
books are two-dimensional and drawn 
from different angles. Students appreci- 
ated the potatoes (and other vegetables 
he used), says Fotuhi, because they pro- 
vided a framework for understanding the 
three-dimensional organization of the brain 
and crossing pathways. 

"Then I came here and I thought, I'm at 
Harvard Medical School, I can't use pota- 
toes anymore!" He wrote a grant proposal 
for $10,000 and, with the support of 
Gerald Fischbach, chair of neurobiology, 
received the money from HST to hire two 
art students from the School of the 
Museum of Fine Arts, Andrew Lisle and 
Hillary Harrison, to build two five-foot mod- 
els. 

All along, Fotuhi admits, he really had 
something much larger in mind. With the 
success of the model, he went back to 
Fischbach and told him of his idea for a 
walk-in model of the brain that would make 
learning fun. "The scheme is ambitious, 
unusual but creative all at the same time, 
says Fischbach. "It is refreshing to witness 
a young physician/scientist who is willing 
to paint in such broad strokes." Fischbach 
gave him names of people to talk to and 
Fotuhi has since written a proposal. 

"The brain is so intimidating to people, yet 
almost everyone is affected or has some- 
one in their family affected by brain dis- 
eases such as headache, depression, 
stroke, Alzheimer's, Parkinson's or MS," 



24 



Harvard Medical Alumni Bulletin 



says Fotuhi. "I have found that once I 
explain to patients in simple terms what 
disease they have, they can cope with it 
better." Knowledge is also the key to pre- 
vention, which is why he also wants to 
show the effects of addictive drugs and 
techniques for reducing stress. 

Fotuhi says that he enjoys making science 
understandable: as an undergraduate at 
Concordia University in Montreal, he 
started a program called "Fun with 
Science" for children ages 6 to 12, which 
he continued at the Maryland Science 
Center. He also taught adult education 
courses on brain chemistry at Johns 
Hopkins and, at Harvard, he now teaches 
neurosciences and pharmacology to HST 
and other HMS students. 

Fotuhi's original concept is a pavilion as 
sketched by the same artist, Andrew Lisle, 
who built one of his brain models. Visitors 
would walk in through the pons into an 
open lobby and take escalators up 
through the cerebral aqueduct to the third 
ventricle. At the bottom and both sides of 
that ventricle is the hypothalamus, where 
there would be an exhibition filled with 
hands-on experiments and games about 
what it is and how it controls sex, thyroid 
and other hormones. From there, people 
could continue by going through the fora- 
men of Monro to the lateral ventricle, and 
on to the different lobes of the brain. In 
the temporal lobe, for example, they could 
learn about Alzheimer's and language 
acquisition, play games to increase mem- 
ory and, in the amygdala, learn about fear. 



]/ h 




In addition to physically exploring areas of 
the brain, Fotuhi would like to use com- 
puter and virtual reality technology so visi- 
tors "walk" to other corners of the brain 
and learn how different lesions affect 
behavior. He pictures people viewing a 3-D 
animation of a neuron by using a com- 
puter program developed by Rick Rogers, 
a consultant in cytobiology and micro- 
scopic tehnologies at the Harvard School 
of Public Health, which would enable peo- 
ple to appreciate neurons exposed to 
alcohol, cocaine and coffee. 

Fotuhi doesn't shy away from a grandiose 
plan that he acknowledges could take 
years to find funding for and to build. He 
tells the story of how he hid in a bathroom 
in his native Iran for two years after gradu- 
ating from high school to escape being 
drafted into the war against Iraq. "I told a 
friend of my father's then that I wanted to 
go abroad, go to the best university, and 
be a doctor. He responded, 'But you can't 
even go out this door.' But here I am." 

After three failed attempts to escape Iran, 
Fotuhi managed to run away through a 
desert to Pakistan, smuggle in his younger 
brother and get them both passports by 
pretending to cooperate with drug smug- 
glers. He then entered Canada as a politi- 
cal refugee. As he attended Concordia 
University, he worked to free the six other 
members of his family one by one; still he 
graduated as valedictorian of his class. 

Fotuhi has already made some progress. 
He has spoken with John Shane, the vice 
president for programming at Boston's 



Artist's rendering of the 
"Giant Brain." 

Above: Majid Fotuhi teach- 
ing with his brain model. 








Museum of Science, who likes the idea of 
the Giant Brain but suggested that he 
write up a proposal for a smaller 3,000- 
foot exhibition that could be mounted 
inside the museum. Fotuhi has also 
reached William Winn, professor and direc- 
tor of the Learning Center at the Human 
Interface Technology Laboratory at the 
University of Washington (their virtual real- 
ity program). Some researchers at this 
center are using virtual reality to simulate 
the environment inside the neuron when 
the body intakes various drugs — just what 
Fotuhi wanted to incorporate into the exhi- 
bition! They have agreed to collaborate 
with Fotuhi and further develop their virtual 
reality systems to simulate the environ- 
ment inside a neuron and then inside the 
brain. "Imagine experiencing the speed of 
action potentials traveling down an axon," 
says Fotuhi. 

Though his ultimate project, the "Giant 
Brain," may be years away, Fotuhi is 
clearly excited about the positive 
response. "My number one passion is tak- 
ing care of patients, but I can envision 
spending part of my time after residency 
on this project," he says. "This is a dream 
I've had and I think it's a worthy dream." 

Ellen Barlow 




Spring 1996 



25 



26 



Harvard Medical Alumni Bulletin 



HMS 

Spins 

a 

Web 



by Terri L. Rutter 




The Internet, that super network 
of computers zapping information 
across town and across the sea, is 
changing our world. What once was 
the realm of military scientists and MIT 
computer geeks is now accessible to 
king and commoner alike. The 
Internet savvy know how to quickly 
retrieve daily stock information, find a 
movie review and learn a thing or two 
about chronic fatigue syndrome. It's 
getting to be that if you're not wired, 
not on-line, if you're not cybernating 
then you're technologically hybernat- 
ing. 

"We recognized early on that the 
Internet was going to be a powerful 
tool," says Judith Messerle, Countway 
librarian for the Harvard Medical and 
Boston Medical libraries. "As soon as 
it opened, we knew we were going to 
play." 

Located on the lower level of the 
Countway Library, out of sight from 
the journals, books and copy machines, 
is the command center for HMS's gate- 
way to the Internet: the "server" — a 
Sun Spark lo Unix system with 7 giga- 
bytes. (In cybermetric, 1 gigabyte 
equals 1,000 megabytes.) The server 
literally serves as the relay station for 
HMS's connection to the World Wide 
Web — the Internet interface filled 
with pictures, voices and quick links to 
a world of information. It hosts the 
HMS home page (a "home page" is the 
welcome mat to a whole series of 
information about the institution and 
related subjects) while providing sup- 
port to users from all over the world 
who visit Harvard Medical School on- 
line; and also connects everyone at 
HMS to their own on-line world travel. 
The server is like the heart, taking in 
and passing out blood cells of informa- 
tion. If the server goes down, the heart 
stops, and well, you know the rest. 

It's taken only two years for 
Countway to amass this level of heavy- 
hitting computer power, but, says Tim 
Fox, system administrator at 
Countway who commands the server, 
as more and more people "hit" 
(Internet lingo for "visit" or read) the 



Spring 1996 



27 



HiMS home page, even this intense 
amount of horsepower is strained. In 
just one month in 1995, 600,000 files 
were downloaded from the HMS site. 

"We're now the public face on- 
line," says Messerle. 

Elizabeth Wu, assistant director for 
planning and systems at Countway 
Library, was the first to recognize the 
Web's potential for Countway and for 
the school. "It instantly provides access 
to the global community," says Wu. 
"The user will now find you instead of 
you trying to find the user." 

Not only does the World Wide 
Web make it easier for an alumnus in 
Switzerland to know what's happening 
with his alma mater, but also people 
from less privileged countries or com- 
munities in the United States now 
have access to Harvard libraries — a 
phenomenon rarely, perhaps even 
never before possible. 

"It equalizes everyone," says Wu. 
"You used to have to come to Harvard; 
with the World Wide Web, Harvard 
comes to you." 

The World Wide Web can be 
thought of as an electronic book with 



an infinite number of pages. Unlike 
those with embossed spines sitting on 
shelves, however. World Wide Web 
pages are a combination of text, color 
pictures, sounds, moving pictures and 
even three-dimensional images. Like 
Prospero's books in The Tempest, these 
pages may even at times seem magical, 
holding vast amounts of information 
and maybe even a few secrets. 

The most vivid example coming 
from HMS is the "Whole Brain Atlas" 
by Keith Johnson (see sidebar). As part 
of this site, a movie shows, in quick 
succession, the lesions that appear over 
a span of time within a multiple scle- 
rotic brain. "Something like that just 
doesn't exist in print," says Wu. 

Because the Web so dynamically 
exceeds the limitations of the printed 
page, particularly in regards to pro- 
ducing clinical and research informa- 
tion quickly, on-line journals are 
becoming popular sites. Also linked to 
the HMS home page is the DJO, or 
Digital Journal of Ophthalmology. 
Edited by Frederick A. Jakobiec '68, 
Henry Willard Williams Professor of 
Ophthalmology, the DJO is a peer- 



review journal that operates similarly 
to a print journal: it accepts both clini- 
cal and basic science topics, includes a 
presentation of grand rounds cases and 
original articles. It distinguishes itself, 
however, in its use of an interactive 
knowledge review that is updated 
weekly and a section on patient infor- 
mation, where the lay person can learn 
about common eye diseases, such as 
cataracts. 

The HMS page also links to the 
more traditional "paper" newspieces, 
such as on-line versions of Focus and 
selections from the Harvard Health 
Publications Group. Even this issue of 
the Bulletin is up on-line. 

Just as a caller to the main tele- 
phone switchboard at HMS is con- 
nected to the correct department, so 
does the HMS home page link to places 
in and around and affliated with 
Harvard, such as BrighamRad, an in- 
depth look at the Department of 
Radiology at Brigham and Women's 
Hospital. The department's chairman, 
Leonard Holman, Philip H. Cook 
Professor of Radiology, calls the 
Internet an "idea in evolution" and 



Click Trip 
Through the 
Brain 



The computer wizardry of the 
World Wide Web, with its 
"hypertext" jumps to other 
sources of information, moving 
pictures, even sound, is an 
extraordinary departure from 
typewritten text on a screen. 
But at its basic level, the Web 
is a "useful tool" for someone 
like Keith Johnson, an HMS 
neurologist at the Brigham and 
Women's Hospital, who is co- 
creator of one of the most 
exciting medical sites on the 
Web. 

The Whole Brain Atlas — which 



Johnson created with J. Alex 
Becker, a physicist and soft- 
ware engineer at MIT — is a 
mixture of normal anatomy and 
physiology of the brain with 
case-based examples of brain 
imaging seen in diseases. It 
has a time-lapse movie of a 
brain undergoing acute stroke 
due to embolism as well as a 
one-of-a-kind data set of 
images of the brain in which 
you can observe the lesions of 
multiple sclerosis coming and 
going over time. It lists the 
toplOO brain structures and 
quizzes visitors to name these 
structures. 

There are imaging data sets 
(using MRI, CT and nuclear 
medicine) for 25 neurological 
diseases, which Johnson plans 
to expand to 100. "Our goal is 



to build a reference library of 
neuroimages," he says. It 
won't be on paper or even on 
film; it will only exist on the 
Internet. 

In only five months after they 
started counting in August 
1995, there were 69,924 visi- 
tors to the Whole Brain Atlas 
(http://www.med.harvard.edu/ 
AANLIB/home.html). But when 
Johnson and Becker started 
this project two years ago, the 
Web was in its infancy. What 
prompted them to spend a lot 
of time on something few oth- 
ers, at least in the Harvard 
medical area, were doing? 

"My research has to do with 
image processing," explains 
Johnson. "We saw the Web 
with its potential to use images 



and text as an opportunity to 
make some of our results of 
image processing techniques 
available to medical students, 
neurologists, neuroradiologists, 
neurosurgeons and neuroscien- 
tists." 

Johnson and Becker had found 
a solution to the problem of 
image registration, the align- 
ment of body images in space 
so they match from one time 
point to another. "We look at 
the brain in slices and if you 
don't slice in the same way 
each time, you can't compare 
one time to the next or one 
kind of brain image to 
another," says Johnson. In 
developing their image-regis- 
tration software called 
Superpose, they had accumu- 
lated lots of brain images, plus 



28 



Harvard Medical Alumni Bulletin 



looks to it to provide "innovative solu- 
tions to in the rapid dissemination of 
information about changes in technol- 

ogy." 

Web "surfers" — surfing is the 
trendy term given the act of clicking 
from home page to home page — on 
the HMS page can also link up to the 
Department of Cell Biology. On a 
page of all the faculty in the depart- 
ment, click on his photo and you'll dis- 
cover that John Blenis, associate 
professor of cell biology, is working on 
a project to understand how "two pro- 
tein phosphorylation cascades are 
modulated by growth in several differ- 
ent cell types." Click again and you'll 
get a description of MAP kinase/RSK 
signal transduction. 

Inside the Department of Genetics, 
besides getting necessary information 
about the lab research happening 
there, you can also discover that grad- 
uate student Jason Johnson likes to 
fish, play Ultimate frisbee and hstens 
to David Wilcox. Grad student Cory 
Kostrub's page leads you to the weekly 
menu for the Chinese food truck 



.^^^•|^.^«««WT1««-Wf^< 




" DOCTOR, I FEEL SO INADEQUATE ... I ... I DON'T HAVE A WEB SITE ... ! " 



parked outside Vanderbilt Hall at 
lunchtime. 

On each page in this colorful 
cyber-book called the Web are lines of 
text that are underfined. Called hyper- 
text links, they work like a set of 
Russian nesting dolls, revealing doll 
after doll. Click on one and another 
doll, or page, is revealed. Click on a 
piece of hjqaertext on that page, and 
another page comes up. 

Many pages include a category of 
hypertext lines called "Web Jewels." 
Click here and one can find a virtual 



treasure chest of biomedical informa- 
tion, such as the Bioethics Online 
Service from the Medical College of 
Wisconsin to GASNet, the Global 
Anesthesiology Server Network, to a 
tour through the workings of the 
heart. Many pages from HMS even link 
to ones describing life in the Boston 
area, which include restaurant reviews, 
information on city government and 
the scoop on how to find a hotel room 
during the Boston Marathon. (For 
those who need it, a real gem is the 
BBN Auto Body Repair page. It lists 



Johnson had neurological dis- 
ease cases he had collected 
through the years. 

"We had no idea if people 
would be interested in these 
images." As it turns out, peo- 
ple from a laii^e range of disci- 
plines have "visited" their site: 
from education, publishing, 
pharmaceuticals, NIH, psychol- 
ogy as well as from the neuro- 
logical disciplines they had 
expected. It was designated 
one of the top 5 percent sites 
of all sites on the Internet by 
Point, a service that surfs the 
Internet and reviews the most 
noteworthy sites. 

As Johnson modestly explained 
the probable reason for this 
distinction: "We've had a lot of 
favorable comments about our 



use of hypertext navigational 
tools. When reviewers came 
upon it, they might not have 
known about the brain, but 
they could see the value of 
these tools we developed." 

The two time-lapse cases have 
been particularly well received. 
"We've designed into the Atlas 
the ability to take a guided tour 
through different brain slices 
to see pertinent findings," says 
Johnson. "Certain things are 
best demonstrated by movie, 
that is, rather than moving 
your eyes past a series of data, 
keeping your eyes in one place 
and changing the data." 

In the case of the acute stroke 
due to embolism, by clicking 
on a key on the screen, you 
can see how a lesion evolves 



over time, in this case five 
days. In stroke, the brain 
swells as it accumulates water 
and you can see it get so 
swollen that everything gets 
pushed around. 

Because of image registration, 
says Johnson, the multiple 
sclerosis time-lapse movie is 
one of their most advanced 
data sets, representing 23 
cases over a year's time. You 
can click on the "time" button 
to look at a single slice over 
time, or change the plane 
you're viewing from by clicking 
on the "space" button. There 
are ways to navigate through 
about 1,200 slices. Click the 
spatial button and look at 
images that depict the entire 
brain on one given day, or 
"cine" in the time domain and 



see the lesions come and go 
over time. 

"What this tells us is that 
lesions of MS come and go but 
not in synchrony with each 
other," says Johnson. "It was 
known that lesions come and 
go, but because of the time- 
lapse aspect, this tool allow us 
to see that the lesions are out 
of synch and to observe the 
lesions change in the same 
part of the brain." In the quest 
to find a treatment for MS that 
will rid the brain of all lesions 
at the same time, this tool will 
be an invaluable window. 

At this point, Johnson spends 
very little time on the Whole 
Brain Atlas. He is soliciting 
contributions from researchers 
with other disease data sets 



Spring 1996 



29 



shops in the Boston area and a few 
years' worth of invaluable comments 
from customers.) 

By one route or the other through 
these Unks, the HMS home page con- 
nects to the NIH, the National 
Institutes of Medicine, the Centers for 
Disease Control and the World 
Health Organization. 

So while there's plenty of good 
information to be foimd on the Web, 
obviously, it doesn't take long to leave 
the halls of medicine and enter the 
whacky and off-beat. Somehow a surf 
through the HMS home page mysteri- 
ously calls forth a page for Chocola- 
tier's Best Brownies, complete with a 
picture of delectable-looking brownies 
and a recipe for chocolate chubbies. 
Unfortunately, though, just because 
they look and sound good, and because 
the Chocolatier home page looks like 
it was designed by a professional 
baker, doesn't mean the chocolate 
chubbies necessarily taste good. The 
same appHes to medical information or 
any other kind of information found 
on the Web. 

"Just because it says medical 



doesn't mean we point to it," says Jean 
Charbonneau, a knowledge and con- 
sultation services librarian at 
Countway. His job is finding interest- 
ing and informative Web sites and cre- 
ating links to them from the HMS 
home page. "There is a lot of junk but 
also a lot of good information that you 
wouldn't find anywhere else," he says 
of the growing amount of medical 
information on the World Wide Web. 

But finding the good stuff isn't 
easy. It means surfing for hours at a 
time and sorting through oftentimes 
poorly organized search engines with 
unsophisticated categories. As more 
and more sites enter the Web every 
day — estimates for the number of daily 
users is in the millions — "just keeping 
up will be a challenge," says 
Charbonneau. And finding a good site 
is no guarantee it will stay that way, 
say those who spend a lot of time look- 
ing for them — a particularly dynamic 
challenge for librarians looking for 
Web "acquisitions." 

"If we buy a book and put it on the 
shelf, we know what is in it," says Wu. 
"But with a link, today the content 



and plans to establish a peer 
review process to monitor sub- 
missions for technical as well 
as pedagogical content and 
interest. The contributors' raw 
data will be registered using 
the software he and Becker 
developed. 

The use of the Web in medicine 
is still in its infancy, points out 
Johnson, who says it is not 
clear precisely what needs it 
will satisfy. "But it will cer- 
tainly create new needs." 

Aside from the advantage of 
displaying imaging data, he 
personally finds other 
resources on the Web useful. 
"There are an increasing num- 
ber of useful tools in neurology 
and radiology, such as subspe- 
cialty updates and constantly 



revised electronic textbooks. It 
is a continuing education tool 
as well as a handy reference." 

Though Johnson had no idea 
what impact his "page" would 
have when they started, he 
says the response has been 
gratifying. As he points out, 
there are places in the world 
where this information is hard 
to come by, not just in develop- 
ing countries but in other hos- 
pitals in the United States. And 
though no one is sure what role 
the Web will ultimately serve in 
academic medicine, let alone 
in the world at lai^e, as 
Johnson puts it: "The potential 
is astonishing." 

Ellen Barlow 



looks alright, but someone could 
change it tonight and we wouldn't 
know." 

The other beguiling aspect of the 
Web is that anyone with time, a com- 
puter and the knowledge about how to 
make and put up a Web page can cre- 
ate a site containing medical informa- 
tion, whether that information is right 
or wrong. There's no regulatory board 
overseeing Web content, no electronic 
form of the framed MD to hang on the 
wall. Wu says the scariest thing she's 
seen thus far were instructions on how 
to handle a choking victim: "Who put 
that up there?" she wonders. And, who 
will read it and try it and who may 
choke to death if those instructions are 
wrong? 

Wu says that she and the other 
information specialists at Countway 
employ similar peer review standards 
for linking Web sites to the HMS home 
page as they would to putting a book 
on the Countway shelves. For exam- 
ple, if a site is developed by a known 
organization, such as the CDC or the 
WHO, she says, then they "feel confi- 
dent that it's good." 

Internally, several departments 
have soared way ahead of others and 
purchased their own servers. As the 
technology becomes more sophisti- 
cated, says Fox, "you can run a web 
server on just about any platform," and 
many departments have done that, 
including genetics and cell biology. 

Others departments, however, have 
put up barely more than the name of 
their chairperson and their address. 

The Countway would fike to get 
everyone on the Quadrangle up on- 
line and the people at Countway help 
them accompUsh that by showing 
them how to build a page. After that, 
it's up to individual departments to 
maintain their own. The quality of 
each department's page varies consid- 
erably. 

"They develop it incredibly well, 
or it's in total disarray," says 
Charbonneau. "We just provide a 
hnk." 

As word gets around and more peo- 



3° 



Harvard Medical Alumni Bulletin 



pie and departments want to go on- 
line, ideas about how those pages 
should look and what kind of content 
they should have need to be consid- 
ered, says Wu. She and others will be 
forming a committee to discuss what 
the HMS on-line face should look like. 

"Internally, we're working on pol- 
icy to figure out a way to present our 
own material to the world," says Wu. 
She explains that they want quality 
control, but without incorporating 
bureaucracy to inhibit each depart- 
ment. One issue will be the use of the 
Harvard seal and logos. For example, 
Wu says she wouldn't want to see a 
department put up a rainbow-colored 
seal. "Instead of everyone just invent- 
ing things, we need to set guidelines," 
says Wu. 

So what does the future hold for 
the Internet world? "I can safely say 
that the Internet is here to stay," says 
Charbonneau. "It's not a fad." 

With projections that the paper 
versions of medical publications, such 
as the CDC's MMWR, will soon be 
replaced by electronic formats and 
with more and more popular journals 
existing only in electronic versions, the 
potential for the Internet's future in 
medicine are multifold. That, in con- 
junction with a proliferation of on-line 
support and information groups for 
every imaginable disease and disorder 
(the MGH Department of Neurology, 
for example, hosts on-line discussion 
groups on Guillain-Barre syndrome 
and early-onset Parkinson's disease, 
among others), patients' ability to gain 
pertinent information is determined 
only by their ability to read and type 
and their understanding of the tech- 
nology. 

For those just waking up to this 
brave new world, Wu has some advice: 
"You need to get your feet wet," she 
says. "Be like a kid who's not afraid of 
anything. Just cfick, click, chck!" ^ 

Terri L. Rutter is associate editor of the 
Alumni Bulletin. 



Getting Started 

First off, you need a computer, and just 
about any conriputer will do— that's the 
equitable beauty of it all. So, whether 
you're a Macintosh person or you're deter- 
mined to never use anything but DOS, 
you're still on. If you've got an older com- 
puter already, you may need a memory 
upgrade if you want to be able to see all 
the fun graphics on the 'Net. The operat- 
ing systems of new computers should be 
Internet-ready — ask your dealer. 

Then you need a modem. Higher-end com- 
puters will have built-in modems, or they 
can be purchased as separate compo- 
nents. Again, if you want to download pic- 
tures and graphics, you'll need a baud 
rate (the speedometer, in a sense) of at 
least 14.4K bps (bits per second) and if 
you're really in the mood, get a 28.8K 
bps. For text only, however, a 2400 bps 
will suit you fine. 

The next requisite purchase is a subscrip- 
tion with an Internet connection service if 
you don't already have access through a 
university. America Online and 
CompuServe are the biggest national ser- 
vices. They each offer access to the 
Internet (although there are some restric- 
tions) and each also has an "interface" of 
its own that includes links to information 
on a variety of subjects, as well as chat 
rooms, where people can speak to each 
other on subjects they have in common. 
AT&T has just released an Internet pack- 
age available to all its long-distance cus- 
tomers (MCI and Sprint are on its heels 
with their own), and Microsoft, too, has a 
package. 

These companies offer a way to surf the 
'Net, but you'll have limited opportunities 
to look at the Web. For that, you need a 
more direct connection such as those 
offered by Internet service providers (ISP), 
of which new ones are popping up all the 
time; some are national and others are 
local. For example, in Boston TIAC (the 
Internet Access Company) has offered a 
deal to HMS faculty, students and staff. 
Check your yellow pages or pick up a 
copy of a computer magazine, such as 
Wired or Internet World. 



To view the World Wide Web, you'll also 
need a "browser" such as Netscape or 
Mosaic, which can be downloaded straight 
off the Web, or the ISP will include a 
browser in its start-up software. 

There are several good guides to using 
the Internet, the most basic being hternet 
for Dummies (don't take it personally!). It's 
available in the computer section at any 
bookstore. There's also an on-line guide 
for working your way through the Web: 
http://www.eit.com/web/www.guide/. 
Closer to home, the webspinner for the 
MGH Department of Neurology, John 
Lester, has an easy, fun walk-through 
guide: http://demOnmac.mgh. harvard 
.edu/, then click on Help Me. 

Once you're on-line, you can find a variety 
of medical information, both academic 
and offbeat. A good place to begin might 
be the Harvard Medical School home 
page: http://www.med.harvard.edu. If you 
want to go elsewhere, click on Web Tools 
and you'll find lists of links to a variety of 
places and subjects. Or, you can access 
some of these places directly using the 
following URL addresses. Happy clicking! 

National Institutes of Health 

http://www.nih.gov 

National Library of Medicine 

http://www.nlm.nih.gov 

Centers for Disease Control 

and Prevention 

http://www.cdc.gov 

U.S. Medical Libraries List 

http://www.kufacts.cc.ukans.edu/ 

hytelnet_html/USOOOMED.html 

WWW Virtual Library: Medicine 

http://golgi.harvard.edu/biopages/ 

medicine.html 

The Visible Human Project 

http://www.nlm.nih.gov/extramural_ 

research. dir/visible_human. html 



http://www.cdc.gov/epo/mmwr/ 

mmwr.html 

Department of Health and Human 

Services 

http://www.os.dhhs.gov/ 

World Health Organization 

http://www.who.ch/ 

Food and Drug Administration 

http://www.fda.gov/ 



TLR 



Spring 1996 



31 










operating in 3 -D 



by Ellen Barlow 



32 



Harvard Medical Alumni Bulletin 



h 



Virtual reality is virtually here, 
at least in one operating room at 
Brigham and Women's Hospital. As a 
patient lies in a revolutionary open- 
design magnetic resonance (mr) scan- 
ner, the surgeon is guided through 
layers of tissues by real-time 3-D 
images. He or she can virtually "see" 
the blood vessels and tumor volume 
beyond the surgical field just by look- 
ing up at a monitor. 

None of this would be possible 
without the computer. It is computer- 
assisted technology, a simple term that 
belies the complexity of an undertak- 
ing that has made real-time image- 
guided surgery realistic and fast 
enough to be reliable. 

This surgery also would not have 
been possible without the vision of 
Ferenc Jolesz, HMS associate professor 
of radiology, whose brainchild the 
open-MR scanner was. He persuaded 
General Electric to build the proto- 
tjqje, which has been in experimental 
use at the Brigham since 1994. It has 
been used for abdominal procedures 
and, since last summer, neurosurgeons 
have performed brain biopsies with 
their patients lying inside the scanner. 
The first open-brain procedures began 
in February 1996. 

Jolesz, director of the bwh's 
Division of Magnetic Resonance and 
of the image-guided therapy program, 
and Ron Kikinis, HMS assistant profes- 
sor of radiology and director of the 
BWH Surgical Planning Laboratory, 
have been working on the technologi- 
cal challenges of image-guided surgery 
the past six years. Diagnostic MRI pro- 
duces beautiful, high-resolution 
images, but they take a few hours to 
process. Only in the past year have the 
Brigham and GE researchers made 
enough progress on some of the scien- 
tific and engineering challenges that 
the intraoperative imaging process has 
been fast enough and resolute enough 
to be useful during surgery. Plus, 
because of the magnetized environ- 
ment in the special open-MR operating 
room, the anesthesia machines and 
every one of the thousands of surgical 



steel instruments are being tested and 
if necessary, redesigned to be compati- 
ble. 

The concept of using imaging as a 
direct means of therapy is not new, 
points out Jolesz. Surgeons and inter- 
ventional radiologists have been using 
ultrasound and fluoroscopy for real- 
time imaging for many years, but these 
methods yield limited, imprecise tissue 
information. A more recent method 
uses CT and frame-based stereotactic 
guidance, plotting with grids, but these 
are previously acquired CT images and 
lack the real-time dimension necessary 
for making continual adjustments. 

"Generally the way surgeons have 
worked over the past 100 years is to 
come down to radiology and look at 
films," explains Jolesz. "They either 
just remember a mental image of it or 
take the film to glance back at. But it is 
just one cut, not a three-dimensional 
view." 

There is inherently more informa- 
tion that radiology can provide the 
surgeon, the actual coordinates of the 
target, for example. But until recently, 
"The images weren't being used as a 
roadmap, because they were not pre- 
sented in a way that the surgeon faces 
in the real world, that is, as 3-D struc- 
tures," says Jolesz. 

Jolesz, who was a surgeon in 
Hungary before coming to the United 
States and retraining in radiology, fur- 
ther describes the visual frustrations 
that surgeons face. "The problem with 
surgery is that we are using a human's 
visual information, light reflected from 
a visual surface. You put one piece of 
paper under another and you can't see 
the one underneath. 

"This is the same problem a sur- 
geon has. If there is a deep-seated 
tumor, you have to go in to see it. The 
target is a volume — say, cherry-sized — 
but you have to make a large incision 
and peel back layer after layer of tis- 
sue. If there are blood vessels under 
one surface, you get bleeding if you 
didn't see them." 

Surgeons want to follow the old 
principle of making the smallest inci- 



sion possible so as not to hurt the nor- 
mal tissue, he explains, but they have 
to be able to visualize the whole lesion. 
Visualization is particularly limited in 
minimally invasive surgery, a trend in 
recent years to use endoscopy and 
"keyhole" surgery to reduce access 
damage. "You may be in the stomach, 
but you don't know what's at the other 
side beyond the hole," points out 
Jolesz. 

These are the spatial limitations of 
surgery, he says. In efforts to minimize 
these limitations, the field of image- 
guided surgery was born five or six 
years ago. 

The germination of Jolesz's vision 
for an MR image's role in all this actu- 
ally goes back a little further. After 
doing a stint in the physiology labora- 
tory of Elwood Henneman in 1980, 
Jolesz decided to stay in the United 
States. Faced with repeating training 
in surgery, he decided to train in a new 
specialty, radiology. He started work- 
ing with MRI when it came to the 
Brigham in 1986, where he was by 
then working. Around this time, he 
recalls, he went to a party and struck 
up a conversation with an ENT sur- 
geon, who mentioned he was using 
laser surgery for tumor treatment. 

"I questioned him about it and 
asked him why if he could cut and heat 
the tumor, he couldn't go deeper 
inside the tumor fiberoptically through 
a needle. He said it was because you 
can't see what the hell you're doing. If 
you use too much energy, you burn 
other tissues; too little and it doesn't 
help. I mentioned that one of the para- 
meters of MR is that you can see heat." 

The idea planted, Jolesz did experi- 
ments in 19B7 and found that image- 
guided laser surgery is possible. That 
led to the development of a technique 
for thermal ablation of tumors under 
MR-guided focused ultrasound, that is, 
real-time image-guided, high-energy 
heating in a focused point. They found 
that cryosurgery also can be guided by 
MR. 

Then he began to think about 
other ways to generate intraoperative 



Spring 1996 



33 



images. MRI struck him as the perfect 
modaht}': it provides excellent tissue 
contrast, often with enough definition 
to allow discrimination between 
lesions that need to be treated and 
those that don't; it was seemingly pos- 
sible to generate three-dimensional 
images; and the imaging sequences 
could potentially be made fast enough 
to allow real-time viewing of physio- 
logical motions. 

He envisioned the adaptation of MR 
technology to an operating room envi- 
ronment and sold General Electric on 
the idea. GE was producing CT, ultra- 
sound and MRI scanners and Jolesz was 
able to convince their executives that 
this was a whole new market, not just a 
shifting of business from one piece of 
the diagnostic-imaging pie to another. 

Their executives made a site visit. 
"They could see millions of dollars 
worth of imaging equipment in radiol- 
ogy — each piece costing $i million 
and each with advanced computer 
technology," he recalled. "Then they 
visited the operating rooms. What did 
they see? Clean rooms with tile, a table 
that could go up and down, a big lamp 



and maybe a few thousands dollars 
worth of electrocautery or laser equip- 
ment. Very low-tech." 

GE built the prototype and devel- 
oped the necessary computer software, 
in collaboration with the BWH group, 
and has spent about $30 million to $40 
million on the project thus far. The 
open magnet looks like a conventional 
MRI with a middle section cut out. The 
patient lies in the tunnel, with the part 
of the body to be operated on exposed 
in the open, middle section, where the 
surgeon or interventional radiologist 
can access it. For neurosurgery, there 
are special, flexible coils shaped like a 
figure eight that wrap around the 
head. 

Images are continuously generated 
every one to ten seconds as the opera- 
tion proceeds, and are superimposed 
and automatically registered with 
images taken by a video camera aimed 
at the operating field. The surgical 
field may be bloodied, but the operator 
can look up at the monitor and see a 
3-D, slowly moving picture of exactly 
where his or her instruments are, and 
can check and plan the course. 



"Even if you're only looking 
through a small hole and can't see any- 
thing with the eye," says Jolesz, "when 
you have an imaging system like this 
with an MR image of a corresponding 
field, unbehevable things can be done. 
There are all sorts of applications." 

Though Jolesz befieves that the 
open MR with active imaging would be 
the ideal way to do all surgical proce- 
dures, it is very expensive at this point 
and requires specially designed equip- 
ment and operating suites. Another 
project he and Kikinis have been 
working on is done in conventional 
operating rooms but uses MR and CT 
images, which are obtained and made 
three dimensional before the opera- 
tion, and then during the procedure 
are superimposed on the image taken 
of the surgical field by a video camera. 
This also provides a roadmap, says 
Jolesz, though is less ideal than real- 
time images. If there has been bleed- 
ing or swelling since the pre-op image 
was taken or if organs shifted even a 
centimeter when the patient was 
opened up, accuracy is compromised. 

This method has been used thus far 




34 



Harvard Medical Alumni Bulletin 



on over loo brain surgery patients, for 
whom this drawback was not a concern 
but accuracy was critical. Advanced 
registration and "tracking" techniques 
developed in Kikinis's lab — in collabo- 
ration with Eric Grimson from MIT 
and the neurosurgery division of 
BWH — provide neurosurgeons with 
three-dimensional image guidance, 
just without the real-time interactional 
capabilities of the open MR system. But 
as with neurosurgery done in the 
open-MR system, planning the proce- 
dure can be done without the less-pre- 
cise stereotactic approach of using 
grids applied to the patient's skull, 
which are then imaged. 

Though surgeons and interven- 
tional radiologists are using the open 
MR and preoperatively-obtained image 
methods, explains Kikinis, extensive 
resources are required. Their ultimate 
goal is still pie-in-the-sky, a few years 
away: to bring a patient into the open- 
MR scanner, push a button, have the 
computer crank out an image which it 
automatically makes 3-D, which the 
operator finds useful at a glance. 
Though major breakthroughs have 
been made in his lab, there are algo- 
rithmic and computational challenges 
that remain. 

The challenges fall into four major 
areas, which Kikinis has approached in 
tandem with each other, "picking pro- 
jects that will help us drive this devel- 
opment." The lab is housed in a 
clinical environment so projects they 
pick have had applications to schizo- 
phrenia, multiple sclerosis and aging 
studies. "We are using clinical prob- 
lems to drive technology develop- 
ment," says Kikinis. The four technical 
areas under development are: 
• Segmentation, the capabiUty to 
automatically produce clinical infor- 
mation out of the data, identifying 
structures of clinical relevance. This is 
the first step of the process that ren- 
ders the image 3-D. Though parts of 
the process are now automatic, Kikinis 
says they'd like the whole process to 
take no more than five minutes rather 
than a total of thirty minutes to two 
days. 



• Registration, to exactly align the 
3-D data information with the corre- 
sponding anatomy of the patient. The 
result is structures as seen in virtual 
reality. 

• Tracking, done by different meth- 
ods: using video cameras, LEDs (light 
emitting diodes) or electromagnetic 
devices. Tracking of surgical instru- 
ments is necessary to get the image at 
the point where the operator is work- 
ing. 

• Visualization. If they solve all three 
of the above problems, says Kikinis, 
then they need to decide how to ulti- 
mately and efficiently present the total 
picture. 

"So we have a palette of techniques 
and each project we do is like a paint- 
ing that uses different techniques to 
get results," says Kikinis. "Our long- 
term goal is to widen the palette and 
make it more robust." Right now they 
have segmentation processes that may 
work with their multiple sclerosis pro- 
ject but not easily with other data sets; 
or processes that work with normals, 
but not in tumor cases. "We want 
algorithms that will work in any case, 
that are robust enough to handle dif- 
ferent resolutions, different patholo- 
gies." 

Their projects are seemingly dis- 
parate, but all are centered on the core 
technology of computerized post-pro- 
cessing of diagnostic medical imaging 
data. Right now this is all very high- 
entry research, says Kikinis, involving 
multi-million dollar equipment and 
lots of people. "But in the long run to 
be meaningful it has to be beneficial 
not only to a few patients in research 
hospitals but to every patient who 
might benefit." 

Automation is so important because 
it reduces the number of trained peo- 
ple who have to be involved and makes 
the process faster. A leap forward in 
the effort to automate was made last 
fall by a computer scientist in the lab, 
William "Sandy" Wells, who with 
Paul Viola, a graduate student in MIT's 
Artificial Intelligence Lab, came up 
with an elegant algorithm that renders 
the video-based tracking technique 



fully automatic. 

"With a person involved there is 
only so much you can do to speed up 
the process," says Kikinis. "Every year 
computers get 1.5 or 1.8 times faster, 
so if there's an algorithm that auto- 
mates, as computers get faster, the 
process gets faster." Speed — both in 
processing and in acquisition of data — 
is the name of the game if the images 
are to be useful in real-time. 

In the meantime, the experimental 
use of the open-MR operating environ- 
ment is expanding. Open-brain 
surgery just began at the Brigham. 
Hospitals in 1 5 other cities around the 
world — including Quebec City, Zurich 
and Palo Alto (Stanford) — will soon be 
receiving and using these machines. 

But whether we'll be seeing suites 
of open-magnet operating rooms in 
the future remains to be seen, says 
Jolesz. One thing he knows for sure: 
"Without computers all of this would 
have been impossible. I could dream of 
it, but it couldn't have been done." ^ 

Ellen Barlow is editor of the Alumni 
Bulletin. 



Spring 1996 



35 



Tel-a-Doctor 



TeiiH L. Riitter 



Telemedicine technology 
makes the far-reaching 
diagnosis of a lung mass 
as easy as child's play. 




r 



^6 



Harvard Medical Alumni Bulletin 



Telemedicine sounds like some- 
thing you do alone in your room with 
a telephone, a mysterious sjmiptom 
and an 800 number. Indeed, telemedi- 
cine is that, but it is also so much 
more. 

Telemedicine has been defined as 
the "investigation, monitoring and 
management of patients and the edu- 
cation of patients and staff using sys- 
tems which allow ready access to 
expert advice and patient information, 
no matter where the patient or rele- 
vant information is located," by the 
Commission of the European 
Communities. Basically, telemedicine 
is employed when a patient is in one 
location and the physician making a 



diagnosis, interpreting a film or just 
offering an opinion is someplace 
else — next door, in the next county, or 
in another country. The means by 
which the physician communicates his 
or her medicine, the "tele," can be a 
telephone or fax, electronic mail, or 
something much more complicated, 
such as sophisticated real-time video- 
conferencing equipment. 

A group of forward-minded physi- 
cians at the Center for Telemedicine 
at Mass. General Hospital are devising 
means of interfacing communications 
technologies with medical practice in 
practical ways that save time and 
money, and exotic ones that link 
patients from as far away as Riyadh, 



Saudi Arabia with specialists at MGH. 

"Telemedicine is creating a global 
medical village," says James Thrall, 
chief of radiology at MGH and an early 
champion of telemedicine's potential. 
MGH specialists in 2 5 departments — 
over 50 physicians — have been 
involved in more than 300 case man- 
agement consultations internationally, 
including Saudi Arabia, Moscow, 
Mexico and Latin America. 

The telemedicine concept itself is 
really very old, perhaps going as far 
back as the first phone call ever 
made — itself prompted by a medical 
emergency. In 1876 Alexander 
Graham Bell made the first 911 call 
after spilling acid on himself and ciy- 




Diagnosis: 



ancer 



Spring 1996 



37 



"Telemedicine is 
creating a global 
medical village. " 



ing out to his colleague through his 
newly invented transmitter: "Mr. 
Watson, come here, I want you." 

Efforts to send medical information 
through a technological medium at 
MGH go back a long way as well, to 
1967 when Kenneth Bird collaborated 
with Thomas Fizpatrick and the 
Raytheon Corporation to use a 
microwave video link and closed cir- 
cuit television to connect the MGH 
with Logan Airport. Although short- 
lived because of the limited technolog- 
ical capacity available at the time, this 
team was able to transmit black and 
white radiologic images and carry out 
projects in cardiac auscultation, physi- 
cal diagnosis, telepsychiatry and 
speech therapy. 

In more modern times, Joseph 
Kvedar, assistant professor of derma- 
tology and medical director of the cen- 
ter, believes the development of 
tele-specialties will create ways to pro- 
vide the often necessary expertise of a 
specialist while saving the cost of 
expensive face-to-face office visits. Just 
last year, for example, Lee Baer, asso- 
ciate professor of psychology in the 
Department of Psychiatry at Mass- 
achusetts General Hospital, conducted 
a successful pilot in telepsychiatry that 
screened for depression. Using voice- 
mail technologies, callers at two 
Midwestern sites were asked to 
respond to a series of comments, such 
as "I have crying spells or feel like it," 
and then directed towards appropriate 
information about where they could 
turn for help. 

Within managed care situations, 
speciahsts are often regarded as a 
rarely used commodity, says Kvedar. 
But patients are used to seeing, and 



expect to see, a specialist. Telemedi- 
cine, therefore can provide an inte- 
grated system of care. "The more 
mergers that happen, the more impor- 
tant the use of this is," says Kvedar, 
who is leading a project at the center 
to study the feasibility of tele-derma- 
tology. 

Ideally, the future of the MGH 
Telemedicine Center could look and 
operate like this scenario: A hj^otheti- 
cal patient, say in Norwood, asks his 
primary care physician about a mole 
he has just noticed. The primary care 
physician thinks a dermatology referral 
is a good idea but his patient is older, 
doesn't drive and can't get a ride to 
Mass. General to see a dermatologist 
until three weeks hence. In the mean- 
time, he's worried and the physician is 
concerned the mole could be malig- 
nant. 

Using a highly sophisticated digital 
camera — which would be provided to 
all affiliated primary care offices — the 
primary takes a digitized photo of the 
mole, then transmits that image to the 
dermatologist's computer at the cen- 
ter. At the end of a day, the dermatol- 
ogist sits at his office computer and 
enters his referral file folder of images. 
He clicks on the Norwood primary 
care physician's file and sees a high 
resolution image of the mole. Beside 
the image is a text file of the patient's 
history and all other relevant informa- 
tion. The dermatologist can assess the 
mole, determine whether it needs a 
biopsy or decide if he should meet 
with the patient to see the mole itself 
He types in his thoughts and sends 
them back to the primary care physi- 
cian, who can retrieve them the next 
morning and call her patient with the 
specialist's recommendations. 

"Telemedicine allows the primary 
physician to do the things patients are 
uncomfortable doing with someone 
they don't know," says Kvedar, who 
cites the examples of talking about dif- 
ficult issues or disrobing for an exami- 
nation. Yet it provides for "a better 
interpretation than the primary care 
physician will have, and at less cost to 



The telemedicine 
concept itself is really 
very old^ perhaps 
going as far hack as 
the first phone call 
ever made. 



the patient than meeting with the spe- 
cialist personally." 

There are problems, however, with 
this picture. 

"Right now the technology exists, 
but it's not fully deployed," says 
Kvedar. The center currently supports 
video conferences and satellite down- 
links for consultation, CME and busi- 
ness meetings. 

Radiology services, on the other 
hand, are handled in conjunction with 
a company called American Telemedi- 
cine, Inc. ATI's roots are in the radiol- 
ogy department at MGH — Thrall was 
one of its founders- — but the organiza- 
tion struck out on its own in 1993. 
Radiologist Mark Goldberg was on 
staff in the department and now 
directs ATI, which has recently been 
acquired by the Dutch company 
WellCare Holdings, NV. ATI is 
involved in many projects promoting 
both the use and the advancement of 
telemedicine nationally and world- 
wide. 

Radiology is so advanced, explain 
Thrall and Goldberg, because radiol- 
ogy images were already digitized 
when the electronic telecommunica- 
tions technology became available that 
could transmit digitized images. This 
specialty distinctly stands out, how- 
ever, because radiologists have the lux- 
ury of being reimbursed for any film 
they read no matter where it was taken 
and no matter where they actually read 
it, excepting a few states. Other spe- 



38 



Harvard Medical Alumni Bulletin 



cialists are not so fortunate. Currently, 
insurance payers won't reimburse 
telemedicine "visits"; every other spe- 
cialist has to see a patient face-to-face 
in order for it to count. 

Licensure and liability are other 
issues to be worked through if 
telemedicine is to have a future. If spe- 
cialists aren't licensed in a state, and 
therefore are unable to practice medi- 
cine in that state, can they offer an 
opinion on a patient in that state via 
telemedicine? If it turns out to be a 
wrong opinion, resulting in a bad out- 
come for the patient, can remote 
physicians be sued, and in what state 
are they liable: the state in which they 
practice, or the home state of the 
patient? Also, the FDA is involved, as 
telemedicine technologies are consid- 
ered medical devices. 

Historically, much of this has been 
inconsequential because internation- 
ally, where telemedicine is most 
prominently used, licensure and FDA 
approval aren't issues. In the United 
States, institutions that have relied 
heavily on telemedicine, such as the 
military and the federal prison system, 
are also not confined by licensure and 
liability issues. Telemedical projects 
have also been explored to serve 
underserved rural areas, where the 
nearest specialist may be hundreds of 
miles away. 



Thrall, however, keeps all the snags 
in perspective. He recalls the days 
when traditionalists absolutely scoffed 
at the idea of transmitting medical 
information over the telephone — 
telemedicine's first technology. 

"I see telemedicine as a natural 
extension for health care in the elec- 
tronic age," he says. He points to what 
has been called a "one-world" concept, 
whereby the fields of banking, with 
ATMs all around the world, news cov- 
erage whereby CNN has a port in every 
town and city world-wide, and rapid- 
fire telecommunications are all con- 
tributing, indeed creating, an 
integrated one-world community. 

"It's medicine's turn to take advan- 
tage of this revolution," he says. ^ 

Terri L. Rutter is associate editor of the 
Alumni Bulletin. 



Spring 1996 



39 



The Digital Clinic 



by Luke Sato 



"Mltltlviedia" has come to mean 
many different things to many differ- 
ent people. In the strict sense, the 
basic elements of multimedia are text, 
graphics, digital video, audio, anima- 
tion and still-images. A subset of these 
elements — mainly text, graphics and 
still images — have been used with 
computers from the beginning. Only 
in the past three years have we seen 
that most computers sold today also 
incorporate digital, video, animation 
and sound. 

Multimedia PCs allow us to effec- 
tively combine these elements to 
deliver information more powerfully. 
Currently, paper-based cases are used 
in tutorial sessions within the core cur- 
riculum courses at Harvard Medical 
School. These cases are designed and 
developed according to the New 
Pathway philosophy of case-based 
learning methodology. Part of the 
impetus for such an approach is to 
offer students not only a clinical con- 
text, but also an incentive and a con- 
text for studying the basic sciences. 

Having a "patient" with whom to 
associate their learning experience 
becomes a powerful motivation to 
study the physiology, anatomy, phar- 
macology and the pathology of the 
human body. This clinical context pro- 
vides students with a focused approach 
to the material. In addition, the 
extrapolation of the case-based 
methodology used within the curricu- 
lum becomes the problem-based 
approach to modern clinical practice. 

However, the use of paper-based 
cases has its limitations. When stu- 
dents are asked later about the details 
of a specific case, frequently they will 
have forgotten the case itself or have 



some difficulty remembering key con- 
cepts that were discussed during the 
case. In other words, there is a lack of 
distinguishing features that identify 
one case from another. Nowadays, stu- 
dents coming to medical school are 
exposed to programs like MTV and to 
computer and video games, which 
have stunning sound and graphics. 
Not only do the graphics and sound 
effects provide a means of catching 
attention, but they are also an effective 
means of communicating information, 
especially to the younger generation. 

To maximize the efficacy of the 
case-based model and to greatly 
enhance their learning experience, stu- 
dents have been asking for more mul- 
timedia-based cases. In addition to 
fulfilling the goals set by the New 
Pathway, multimedia-enhanced teach- 
ing gives students exposure to as many 
"real-life" patients (cases) as possible. 
Adding a "face" to these "patients" 
through multimedia technology makes 
the cases come to life. Students will be 
able to experience clinical interactions 
that they may have little or no expo- 
sure to during the first two years of 
medical school. 

To effectively communicate to stu- 
dents issues of how physicians care for 
dying patients, we designed a multime- 
dia-based software exercise that allows 
students to analyze interactions 
between heath care providers and 
patients. The multimedia program 
described is based on this video and is 
also used in the course in conjunction 
with the video. Scenes within the video 
are incorporated into the multimedia 
program as digital video clips. This 
video was produced by Josh Hauser 
'95 and Lynn Peterson, associate pro- 



fessor of medical ethics in the 
Department of Social Medicine, for 
use in Peterson's Patient/Doctor m 
ethics course. It was used the first time 
this year and will be used again in 
Peterson's course next year. 

In one scene, a woman in her sixties 
is admitted to the hospital for a hernia 
repair. She is later discovered to have 
metastatic ovarian cancer. This case is 
set in the woman's hospital room after 
her surgery. Scenes depicted show dif- 
ferent caregivers talking with the 
patient; she is told of her diagnosis by 
her surgeon, a nurse, a medical oncol- 
ogist and her primary care physician. 

This program has the option to fol- 
low an individual caregiver or to exam- 
ine a number of caregivers talking 
about similar topics with the patient. 
These digitized video clips portray dif- 
ferent styles and manners of relating to 
patients, showing how each caregiver 
opens the interaction, how each closes 
it, how advice is given, or how each 
talks about future plans. Each topic is 
illustrated by digitized video clips 
excerpted from a videotape of the 
patient/provider interactions. The 
program allows close analysis of these 
interactions by placing them side by 
side for comparison. It provides ways 
of preparing students for clinical situa- 
tions they may encounter in real life. 
With paper-based cases, this type of 
nontextual information is impossible 
to convey. 

Faculty were closely involved with 
this project from the initial conceptu- 
alization. We experimented with this 
multimedia application as a facilitation 
tool for discussion among students. 
The program was arranged for display 
to a small audience of students, while a 



40 



Harvard Medical Alumni Bulletin 



I 




Scenes from a Diagnosis: 
Students can clicli and 
follow how four different 
caregivers tell a patient 
she has metastatic ovari- 
an cancer. 



facilitator selected a theme from a 
menu of options. Students were later 
asked three questions: (i) What 
worked well? (2) What worked poorly? 
and (3) What would you change? In 
this example, multimedia elements, 
when used appropriately within 
instructional software, provided a 
more powerful means of communicat- 
ing to students subtle nuances of the 
patient/provider interactions. 

Just as different multimedia ele- 
ments can be an effective means of 
communicating information to stu- 
dents when used in sophisticated 
instructional software, multimedia will 
help transform the ability for physi- 
cians to communicate with each other. 
As changes in health care gradually 
take shape, managed care plans like 
health maintenance organizations are 
restructuring their delivery of health 
care to a wider geographic area. One 
possible scenario for a patient might 
be for the primary care physician to 
send her to one health center to obtain 
a MRI and to another health center 
within the network to have a different 
procedure performed. Hospitals as we 
now know them will evolve to primar- 
ily intensive care facilities, while most 
diagnostic procedures, routine studies 
and follow-up care will be done at geo- 
graphically dispersed outpatient facili- 
ties. 

This type of health care delivery 
will lead to fragmentation unless the 
proper infrastructure is in place to 
provide for efficient and effective 
means of communicating among com- 
ponents within the network. Not only 
are there obstacles in communicating 
among components within a provider 
network, but also between the patient 
and provider as well as between 
provider networks. To compound the 
issue, the surge of information 
resources and data that the physician 
will need to assimilate has increased 
exponentially over the past decade. 

As more and more health care 
providers turn to information and 
computer technology as a way of con- 
necting various components within the 



provider network, multimedia will be 
used as an effective and efficient com- 
munication tool. Not only will multi- 
media become incorporated into the 
provider network system, sophisticated 
systems — implementing an almost 
problem-based approach used in med- 
ical school — will manage and access all 
multimedia-based patient information 
including lab reports, radiological 
studies, on-line medical references, 
electronic, video, and voice mail com- 
munications relevant to that patient. 

Telemedicine will not only be 
point-to-point video conferencing so 
that specialists can consult each other. 
It will also evolve to include multime- 
dia decision support resources, such as 
treatment and management guidelines, 
bibliographic references, images, video 
of patient findings, and radiology 
reports physicians need to have to 
make proper management decisions. 

For example, considering our 
woman with metastatic ovarian cancer, 
in the future the primary care physi- 
cian sitting at her desk could receive a 
video conference call from her patient. 
The physician instantly recognizes 
that the patient looks distraught. 
Initially, the patient denies any prob- 
lems. However, as the physician 
presses her, the patient starts to break 
down and discloses that she is having 
difficulty making a decision whether or 
not to receive chemotherapy for her 
illness. 

Her physician calls up the patient's 
medical record and issues a voice com- 
mand to her workstation: "Please 
retrieve all material related to metasta- 
tic ovarian cancer." Instantly the com- 
puter retrieves all relevant 
information, including current statis- 
tics from a national ovarian cancer 
database comparing survival rates of 
patients with similar findings, patient- 
oriented educational materials, and 
several video correspondences she 
once had with the medical oncologist 
regarding treatment options along 
with attached bibliographic references. 

Currently we view the Internet and 
the World Wide Web (www) as pro- 



Spring 1996 



41 



\'iding a tar less sophisticated version 
of the t\'pe of interaction described 
above. However, we conjecture that 
the next evolution of the \^'\^^V will be 
able to provide true telemedicine capa- 
bilities. As multimedia-based cases give 
students an interesting, focused and 
efficient approach to studying the 
material at hand, future technology 
implementing a similar multimedia 
problem-based approach will enable 
caregivers to make better decisions 
about how to treat their patients and 
hopefully reduce overall costs. 

Luke Sato, MD is an HMS instriicm- in 
radiology and associate director of the 
Innovation Center for Infoiynation 
Technology at the Decision Systents 
Group, Brigham and Woi?ten V Hospital. 



Slight in Hand 

The latest advancement in medical educa- 
tion at Harvard fits in the palm of your 
hand. Well, it actually takes two palms to 
hold it up, and those palms, right now, are 
only on the hands of the second- and third- 
year students. 

In the spring of last year, Hewlett Packard, 
under its university grants program, gave 
the medical school 460 HP200LX comput- 
ers, affectionately called "palmtops." The 
school then made them available to sec- 
ond- and third-year students— if they 
chose to take them — for a trial run; 75 
percent of the third-years and 100 percent 
of the second-years signed up. While sev- 
eral students warily opened their boxes 
and skeptically filed their individual regis- 
tration numbers with staff from the Office 
of Educational Computing (OEC), an intre- 
pid few began digitizing everything from 
their personal address books and financial 
affairs to molecular biology facts and 
patient information. 

"Resources that students used to carry 
around with them are now available on the 
palmtop," says Dale Curtis, educational 
computing coordinator, who brought the 
palmtop to HMS after having managed a 
successful palmtop program at the 
University of Arizona College of Medicine. 



David Tom Cooke and Liane Clamen 




The palmtop measures 5.3 x 3.4 x 1 
inches and weighs 11 oz. It looks like a 
digital personal organizer, it has the same 
uniform gray casing, but it's a little wider. 
(One student wrote in an evaulation of the 
palmtop that the bulkiness of it in the back 
pocket of his scrubs took a little getting 
used to.) The palmtop is powered by two 
AA batteries — what it takes to run a small 
flashlight — and a watch battery serves as 
backup. A DOS-based machine, it comes 
with two megabytes of built-in memory. 
Each student is given a ten-megabyte 
"flash" card, which acts like a disk, and 
compression software that doubles the 
capacity of the card, effectively providing 
an extra ten megabytes of memory. 
Retail, the HP200LX sells for $699, and 
the extra memory card is $600. Hewlett 
Packard donated $600,000 worth of 
equipment to the school. 

The palmtop also comes with a few built-in 
software programs, including an appoint- 
ment calendar, address book, memo pad, 
a version of the Lotus spreadsheet and 
Quicken, the financial planning program — 
an especially crucial tool for students on 
tight budgets. 

But that's all basic fare. What comes next 
separates the HP200LX from that little 
electronic calendar-calculator mom or dad 
got for Christmas: it's chock full of med- 
ical information, from descriptions of all 
the basic disease entities to the vital sta- 
tistics of the patients who have them. 
Students were given a software package 
for Outlines In Clinical Medicine, an elec- 
tronic simulacrum of the Washington's 
Manual, which, for many, has usurped the 
bulkier book that was a staple for genera- 
tions of anxious medical students. 
Acquiring other databases is in the works, 
including commercial ones for drugs, for 
example, and new ones continue to be 
developed. 

"It makes the retrieval of information more 
efficient," says Carl Marci '97, one of the 
palmtop's biggest proponents. "In medi- 
cine, that's the name of the game." 

Marci early on began developing data- 
bases and templates for use on the palm- 
£ top. He's created separate databases to 
I record patient information upon admis- 
%. sions, and on rounds. The latter is espe- 
I cially efficient since students are required 



42 



Harvard Medical Alumni Bulletin 



to keep detailed daily records of each 
patient they see. Typically, students carry 
around a thick stack of 3" x 5" index 
cards in their pockets; each day, each 
patient gets a new card with all of his or 
her medical information carefully copied 
from the day before. With Marci's palmtop 
template, the first day's information is 
copied with the press of a couple buttons 
onto the next day, and then only the new 
or changed information needs entering. 

Marci and classmate Sam Somers formed 
a core group of students to share informa- 
tion and to develop programs that enable 
the palmtop to be used more efficiently. 
They are developing a page linked to the 
HMS home page that will describe all the 
new programs being created, which stu- 
dents will be able to download for their 
own use. The page will also provide gen- 
eral encouragement and instructions on 
using the palmtop. 

A miniature modem enables students to 
interface with Countway and with the HMS 
e-mail server. (Eventually, students may 
even be able to log on to the computer 
systems in the different hospitals.) Thus, 
they can do a Medline search and check 
their e-mail from anyplace with a phone 
jack — ^the hospitals or at home. An 
infrared sensor on the side of the com- 
puter makes transferring files from one 
computer to the other a snap: just aim 
two spots together and zap. You can do it 
in the MEC, you can do it in Countway, you 
can do it on the shuttle, you can do it just 
about anywhere. The school also pur- 
chased innocuous-looking little black 
boxes equipped with the infrared readers. 
These boxes hook into laser printers and 
allow students to print files, by aiming 
infrared at infrared, right from their palm- 
tops. Right now, there is one such reader 
in the MEC, which creates a long line of 
students, palmtops in hand, at deadline 
times. 

The medical school has also installed 
infrared readers on printers in a few of the 
hospitals so students can easily print out 
their admission and progress notes. (This 
may partially explain rumors of a few resi- 
dents' covetous reactions to the palm- 
tops, including one who is purported to 
have banished their use when he — or 
she — is around.) 




Carlin Chi (left) and Myrtha Cesar open their palmtops. 

Most of the reaction from residents and 
attendings, however, has been positive. In 
fact attending David Soybel, assistant pro- 
fessor of surgery at Brigham and 
Women's Hospital, even requires the palm- 
tops in his surgery clerkship. 

"I frankly think we're coming to the point 
that [the palmtops] are going to become 
indispensable," says Soybel, "whether we 
like it or not." 

Not only is the palmtop having an impact 
on how students are able to organize 
medical information as they learn it — 
Marci's has helped him purge "all those lit- 
tle slips of paper that used to cover my 
desk and drive me nuts" — but, if things go 
the way Soybel would like, the palmtop will 
also have an impact on the way students 
are taught. Included in the palmtop's soft- 
ware is an evaluation form for each clerk- 
ship. Unlike the paper evaluations 
students fill out at the end of the clerk- 
ship, the palmtop allows them to evaluate 
their experiences at the end of each day. 
In the end, faculty expect these daily sum- 
maries will provide a more thorough 
account of students' clerkship experi- 
ences. 

Soybel especially sees the potential of the 
palmtop's quick efficiency. "You can't have 
managed care without managed informa- 
tion," he says. "Students have to utilize 
these tools or they can't operate in a man- 
aged care environment." 



How useful the palmtop turns out to be to 
medical education will be determined 
when the pilot phase of the project is over 
at the end of the year. Early results, how- 
ever, indicate that the experience has 
been favorable enough that the medical 
school has applied for a second grant 
from HP to provide the palmtops to the 
classes that currently lack them. 

Its usefulness to students like Marci, how- 
ever, has already been confirmed. "I'll go 
into even more debt to buy one," he says. 
Many students may be doing the same 
thing because once they graduate, they 
have to give them back. 

Tern L. Rutter 



Spring 1996 



43 



Brave New 
Interviewer 



hy Warner V. Slack 




44 



Harvard Medical Alumni Bulletin 



I HAD THE GOOD FORTUNE TO SPEND 
the decade of the 1960s at the 
University of Wisconsin in Madison, 
where a wonderfully radical atmos- 
phere of strong social conscience and 
progressive ideology pervaded the 
campus. Remarkable science was being 
done there as well. Gobind Khorana 
was synthesizing a gene in a test tube, 
Howard Temin was postulating 
reverse transcriptase in RNA viruses, 
Milton Yatvin was lending new under- 
standing to the hormonal control of 
genetic expression, Harry Harlow was 
elucidating the psychological bonds 
between mother and infant, and Carl 
Rogers, in a small, two-story cottage 
on University Avenue, was evolving 
his theory of nondirective psychother- 
apy. 

It was in this environment, recep- 
tive as it was to ideas that departed 
from the traditional, that two lines of 
reasoning evolved and converged in 
my mind. The first line of reasoning 
led to the conclusion that the com- 
puter could be used wisely and well in 
the practice of medicine. The elec- 
tronic digital computer, with its capac- 
ity to hold large amounts of data and 
to execute multiple complex instruc- 
tions with great speed and accuracy 
would, I reasoned, find an important 
clinical role in both diagnosis and 
treatment. Investigators in a few insti- 
tutions had begun to explore the use of 
the computer in diagnosis, but the 
computer in medicine under any cir- 
cumstances was then a radical depar- 
ture from tradition, and there were 
many voices of concern about dehu- 
manization and the demise of the art 
of medicine. 

The second line of reasoning led to 
a philosophy that I called "patient 
power" in the vernacular of the times, 
arguing that patients who want to 
should be encouraged to make their 
own clinical decisions and helped to do 
so. For centuries, the medical profes- 
sion had perpetrated paternalism as an 
essential component of medical care, 
thereby depriving patients of the self- 
esteem that comes from self-reliance. 



The assumption was that the doctor 
knew best. Patient power questioned 
this assumption. 

Like the idea of computers, the idea 
of patient power was highly controver- 
sial for its time, and the debate was 
frequently lively, among friends and 
enemies alike. In 1961, during a visit 
to our home in Madison, my brother 
Charles took me to meet Carl Rogers, 
who had introduced the concept of 
client-centered therapy to clinical psy- 
chology. This meeting was one of the 
turning points in my life. Rogers's sup- 
port of patient power was the rein- 
forcement I needed to persevere. 

I put my ideas to the test in clinical 
practice at the University Hospitals in 
Madison, during neurology residency, 
and at Clark Air Base Hospital, during 
two years in the Philippines. I was 
convinced that with patients' input, 
medical records would be much 
improved. With the license to write 
behind a patient's back, as has been the 
tradition in Western medicine, factual 
errors that the patient could correct go 
uncorrected. Furthermore, there is a 
natural tendency to find fault with the 
patient when difficulties arise; diag- 
noses such as "inadequate personality" 
would have disappeared quickly if 
patients had seen them early. 

Out of the Air Force and back in 
Madison, I continued to pursue my 
interest in clinical computing and 
patient power. Although my ultimate 
goals were to use the computer in 
diagnosis and treatment, it was clear 
that if the computer was to be of any 
help in medicine, good information — 
i.e., from the medical history, the 
physical examination, and the results 
of diagnostic studies — would have to 
be collected. My officemate, Philip 
Hicks, was working to automate the 
clinical laboratories; I decided to start 
with the medical history. In collabora- 
tion with Hicks, Lawrence Van Cura, 
and other colleagues, I hypothesized 
that we could program a computer to 
take a medical history directly from a 
patient. 

The motivation came in part from a 



theoretical question: Could a com- 
puter model the physician? Could it 
actually interview a patient? There 
were also practical motives. For the 
busy clinician, particularly in areas of 
our country that are medically under- 
served, there is barely enough time to 
ask "Where does it hurt?," let alone all 
the other questions in the standard 
interview. In America, taking medical 
histories is a time-consuming and 
expensive process; talk is not cheap in 
medicine. 

In the sixties self-administered 
paper questionnaires were being used 
with some success; the Cornell 
Medical Index and the "multiphasic" 
questionnaire of the Permanente 
Medical Group provided standardized, 
consistent, and inexpensive methods 
for taking medical histories. And many 
good self-administered questionnaires 
are used throughout the country 
today. Questionnaires, however, can- 
not be tailored to the individual situa- 
tion because they don't permit 
interaction. They provide no mecha- 
nism to clarify the patient's meaning 
or to qualify answers about symptoms. 
If the patient answers "yes" to the 
question, "Have you ever coughed up 
blood?", this could mean a speck from 
the nose ten years ago or a massive 
hemoptysis last week. The patient may 
misunderstand a question (and thereby 
give an erroneous answer), inadver- 
tently skip a question, or lose one or 
more pages of the questionnaire. 

Our idea was to incorporate into 
the program at least some of the 
advantages of the physician as inter- 
viewer: the ability to explore abnormal 
findings in detail and to personalize 
the interview in an appropriate, digni- 
fied and considerate dialogue with the 
patient. At the same time, we wanted 
to gain the advantages of the question- 
naire: its completeness, standardiza- 
tion and economy. We hoped that 
individual computer-based histories 
would be helpful to patients and their 
physicians; that the computer would 
be of interest to patients (perhaps even 
enjoyable); and that the pooled 



Spring 1996 



45 



responses to the intemews would help 
us learn more about the medical his- 
ton' and the process of clinical inter- 
\ie\\"ing. 

Some of our colleagues considered 
the idea radical. Those who ques- 
tioned the use of computers in medi- 
cine were particularly concerned about 
the use of one to take a medical his- 
tory. Some said it could not be done; 
others wondered if it should be done. 
Still others said that patients would 
find the idea offensive and would 
refuse to be interviewed by a com- 
puter, regardless of the nature of the 
program. (Years later, in completion of 
the critic's circle, they would ask, 
"Isn't everybody doing it?") 

Patients, however, were remarkably 
enthusiastic. "It sounds like fun" and 
"I'd like to try my hand with a com- 
puter" were typical responses, particu- 
larly if (as was most often the case) 
they had never seen a computer. Their 
one concern was that the computer 
might try to do an "intelligence" test, 
which I assured them would not be 
done. 

We decided to start with allergies 
for our first computer-based history. 
This seemed like a neutral, inoffensive 
subject for a computer; it is a field of 
great medical importance that relies 
heavily on the medical history, and our 
allergist consultant, Charles Reed, 
gave his enthusiastic support. We also 
mistakenly thought that an allergy his- 
tory would be short. By the time we 
called a halt to expansion (Charles is 
very thorough) there were over 500 
questions in the program. 

Philip Hicks suggested that we use 
the LINC (laboratory instrument com- 
puter) for our study. This small, gen- 
eral-purpose digital computer was 
developed at the Massachusetts 
Institute of Technology in 1962 by 
Wesley Clark, Charles Molnar and 
their colleagues. It was a pioneering 
machine, and in many respects was the 
forerunner of today's personal com- 
puters. With it, the individual user 
could exert maximum control over the 
computer — a major departure from 



After a while it 
became clear that 
there was (I could 
think of no other 
word for it) rapport 
between man and 
machine. 



the batch-processing brontosaurs of 
the day. It was well suited for "on- 
line" collection (that is, collection of 
data directly by the computer) and 
"real-time" processing (processing 
data as fast as they are generated) of 
experimental data. 

Our plan was to program the LINC 
to communicate with the patient by 
means of questions, explanations, 
requests and comments displayed on 
the cathode-ray screen; the patient, in 
turn, could communicate with the 
computer by means of the typewriter 
keyboard. The LINC had a very small 
memory by today's standards — 1,024 
1 2 -bit words — barely enough to hold 
the text for one question, together 
with the instructions in the program 
that told the computer what to do. 
(The off-the-shelf personal computer 
of today has about 4,000 times as 
much memory as the LINC.) 

Two magnetic tape drives, which 
could turn equally well in either direc- 
tion, provided additional storage space 
for text and instructions that were not 
in use, which could quickly be called 
into memory when needed. 

We used one of the original LiNCs, 
which had been brought to the 
University of Wisconsin's neurophysi- 
ology laboratory by Joseph Hind. The 
machine was in great demand, and 
programming time during the day was 
scarce; we did most of our work 



between 10:00 PM and 8:00 AM. 

I approached one of our medical 
interns, who seemed amused by the 
idea of the computer-based history; he 
was sleep deprived, and the thought of 
being replaced by a computer, at least 
at night, had a distinct appeal. He sug- 
gested a patient who might be willing 
to help, an elderly man who was recov- 
ering from a heart attack and was now 
up and about, getting ready to go 
home. I went to his room, introduced 
myself and told him the general idea of 
the project. He replied that he would 
try anything once, and walked with me 
to the medical sciences building, 
where the LINC was housed. 

The tapes churned and "HAVE YOU 
EVER HAD HIVES?" appeared on the 
screen. The characters flickered, the 
lights on the console flashed on and 
off, and the LINC's speaker emitted an 
eerie, high-pitched sound. On the 
other side of the sheetrock partition, 
people were walking in and out, and a 
cat that was part of a brain experiment 
was meowing. It was somewhat like 
Kafka's Castle or Koestler's Darkness at 
Nooii. Clearly not optimal circum- 
stances for a medical interview. 

Yet my newfound friend seemed 
oblivious to his surroundings. He got 
going at the keyboard, responding to 
the questions, and after a while it 
became clear that there was (I could 
think of no other word for it) rapport 
between man and machine. He 
laughed out loud at some of the com- 
ments fi-om the computer. (Some I had 
intended to be funny; some I hadn't.) 
And he talked out loud to the machine, 
sometimes in praise and sometimes in 
criticism. 

"That was a dumb question," he 
noted with a chuckle. "You already 
asked me that!" He was right, of 
course, yet he never would have said 
this to me face to face, a doctor with a 
white coat and Bakelite nametag. At 
the conclusion of his interview, he 
turned to me and said, "You know, I 
really like your computer better than 
some of those doctors over in the hos- 
pital." Surprised, I asked him why. 



46 



Harvard Medical Alumni Bulletin 



"Well, for one thing, I'm sort of deaf 
and have trouble hearing them." 

For each of the possible responses 
to the computer's questions, we had 
developed phrases that could be 
printed as a summary for the physi- 
cian. When our first patient had com- 
pleted his interview, I was relieved to 
hear the teletype chatter as it began to 
print; the summary program was 
working. 

He then turned to me and said, 
"What's happening? May I read 
that?" I could not think of any reason 
why he shouldn't. Once again, the 
computer was helping him to assert 
himself as a patient. 

As he started to read, he suddenly 
commented, in reference to some 
details about his hay fever: "No, that's 
wrong; I didn't mean that." He then 
proceeded to pick up a number of 
other errors. Clearly, there were mis- 
takes in the interview. Yet if he hadn't 
asked to read his summary, I never 
would have known. Since that time we 
have asked our patients (whenever they 
are willing) to read their summaries 
and help us edit their medical histories 
and improve our computer-based 
interviews. 

Encouraged by the results of this 
first interview, we did a more formal 
study. Fifty hospitafized patients vol- 
unteered to have their allergy histories 
taken. In each case, the results of the 
computer's history were compared 
with the allergy history as recorded in 
the hospital chart by the medical stu- 
dent, intern and resident attending the 
patient. None of the patients' charts 
mentioned an allergy that was not also 
described by the computer. For 
patients whose charts gave no indica- 
tion of allergies, the computer eficited 
two cases of asthma, seven cases of hay 
fever, twelve cases of hives, and one 
case of allergy to penicillin. 

In another case, the mention of 
"penicillin allergy" in the chart was 
insufficient to determine whether an 
allergy actually existed, whereas the 
computer described the single reaction 
in detail and left no doubt that a 



"You knoWy I really 
like your computer 
better than some of 
those doctors over in 
the hospital. " 



serum-sickness type of reaction had 
occurred. All drug reactions were 
described in more detail by the com- 
puter than by the students and physi- 
cians. On the other hand, the 
computer elicited and printed out 
some false positive information, such 
as an allergic reaction to phenobarbital 
that was later described by the patient 
as "excessive grogginess." 

As we had hoped, almost all of the 
patients found their interaction with 
the computer both interesting and 
enjoyable. When asked to compare the 
computer with physicians in their 
experience, 20 patients had no prefer- 
ence, 1 2 indicated a preference for 
physician-taken histories and to our 
surprise, 18 indicated a preference for 
the computer-based system. 

Heartened by these early results, 
we continued to study computer-based 
medical histories in our laboratories at 
the University of Wisconsin and, 
beginning in the early seventies, at the 
Beth Israel Hospital in Boston, when I 
joined Howard Bleich to form the 
Division of Clinical Computing in the 
Department of Medicine. We devel- 
oped and studied a general review of 
systems (conducted in French and 
Spanish, as well as English) and histo- 
ries for patients with problems such as 
uterine cancer, epilepsy and headache. 

We also ventured into a field that 
was somewhat more controversial for 
the computer. We developed a psychi- 
atric history, designed as a general 
review of behavioral problems, and 
gave it to 69 volunteers who had been 



scheduled for psychiatric evaluation. 
As with other computer histories, the 
patients reacted favorably and indi- 
cated a slight preference for the com- 
puter as interviewer over physicians. 

A finding of great interest to us in 
those early days of patient/computer 
dialogue, one since corroborated by 
further study, was that patients often 
found themselves more comfortable 
communicating information to the 
computer about potentially embarrass- 
ing matters, such as sexual activity and 
emotional problems, than they would 
have been talking to their physicians. 
When we programmed a computer 
interview to facilitate soliloquy, we 
found that subjects, when encouraged 
by the computer, talked easily into a 
microphone, first about anxiety-pro- 
voking circumstances and then about 
relaxation. As an indication of the 
effectiveness of the program, both 
mean heart rate and "State anxiety" 
scores of 42 volunteers fell signifi- 
cantly between the beginning and the 
end of the interview. 

In the meantime, others began to 
work actively in the field. A general 
medical history, with emphasis on the 
review of systems, was developed and 
studied at the Mayo Clinic, and both 
patients and physicians reacted favor- 
ably. Another general medical history 
was studied at the Massachusetts 
General Hospital, where patients 
reacted favorably. Physicians' attitudes 
were mixed, but the computer's sum- 
maries were in good agreement with 
the physicians' own findings. 
Meanwhile, other investigators were 
developing and evaluating histories in 
specialty areas, such as psychiatry and 
psychology, nutrition, headache, vene- 
real disease and allergy. And the field 
of computer-based interviewing 
remains active. 

Yet the idea of a computer taking a 
medical history can still evoke worri- 
some thoughts: 2001: A Space Odyssey 
or Tery?iinal Man, Orwellian thought 
control. But the experience of our first 
patient, and the majority of patients 
who have subsequently engaged in dia- 



Spring 1996 



47 



logue with computers, was the oppo- 
site of what some had predicted. This 
man had gained control, not lost it. 
For the first time in his role as a 
patient, he was in charge; he was mas- 
ter of his own history. And, in his 
\\'orld of dealhess he could communi- 
cate particularly well with the 
machine. 

In the spring of 1970, 1 presented 
my ideas on patient power and clinical 
computing to the "Second Conference 
on the Diagnostic Process," held at the 
University of Michigan in Ann Arbor. 
Those in attendance were divided in 
their reactions, and the ensuing debate 
was heated. The moderator, John 
Romano (chair of the Department of 
Psychiatry at the University of 
Rochester) staunchly defended the 
right of the physician to direct the 
patient ("patients want to be told what 
to do"); Leonard Savage (professor of 
statistics at Yale), on the other hand, 
said that he "was particularly pleased 
to hear the bold and radical defense of 
the thesis that medical values should 
be those of the patient." 

The debate was to continue 
through the 1970s. Franz Ingelfinger, 
editor of The New England Journal of 
Medicine, rejected my article "The 
Patient's Right to Decide," making it 
clear that he strongly disagreed with 
my position. On the other hand, Ian 
Monroe, editor of the Lancet (and to 
whom I will be forever grateful), sent 
me an encouraging letter of acceptance 
and pubhshed my article forthwith. 
But all agreed during those decades of 
debate that when it came to dialogue 
between patient and computer, the 
patient should be in charge. Ironically, 
it would be easier to transfer control to 
the patient by means of an automaton 
than by means of the physician. 

It is my premise that the largest yet 
least used health care resource, world- 
wide, is the patient or prospective 
patient and that the interactive com- 
puter can be used beneficially to 
enlighten patients and empower them 
in the health care process, thereby 
improving the quality of care while 



Ironically^ it would 
be easier to transfer 
control to the patient 
by means of an 
automaton than 
by means of the 
physician. 



reducing the cost. There are a number 
of common important medical prob- 
lems, such as sore throat and urinary 
tract infection, that patients could 
manage alone if they were provided 
with the clinical information necessary 
to do so. 

Whether clinical management is 
primarily the responsibility of the clin- 
ician or the patient is often dictated by 
forces of supply and demand. If, for 
example, the biochemistry of insulin or 
the physiology of the pancreas were 
such that a child with juvenile diabetes 
needed only one insulin injection per 
year, it is likely that an academic 
endocrinologist in a teaching hospital 
would give the injection, but at consid- 
erable expense. If the child needed an 
injection every six months, the pedi- 
atric diabetologist would give it; if 
every three months, the primary care 
physician; and if once a month, the 
nurse practitioner. But since the child 
needs the insulin at least once a day, 
the parent or child is responsible for 
administering the injection, without 
assistance. And the parent or child 
usually does this skillfully, conve- 
niently and at low cost. 

In our laboratory in the Center for 
Clinical Computing, at Harvard 
Medical School and Boston's Beth 
Israel Hospital, Hollis Kowaloff, Doug 
Porter, our colleagues, and I have 
studied the interactive computer as a 



patient's assistant in a variety of other 
health-related areas. In nutrition, in 
collaboration with Jelia Witschi, we 
developed a three-part dietary coun- 
seling interview, which asks questions 
dealing with general dietary behavior, 
elicits details of food intake on an 
average day, and plans with the patient 
a weight-reducing diet of approxi- 
mately 1 500 kcal. During the inter- 
view, the program offers dietary 
suggestions and, on completion, gen- 
erates a printed summary for use by 
patients and nutritionists. 

We have also developed and stud- 
ied a program designed to assist 
women in caring for uncomplicated 
urinary tract infection. The program 
takes a history of the present illness 
(e.g., "Are you bothered by pain or 
burning when you urinate?"), per- 
forms a review of systems, interprets 
laboratory data, suggests referral when 
additional medical problems are indi- 
cated, tests the reliability of important 
questions by repeating them, resolves 
uncertainties that the patient may have 
(e.g., when the patient does not imder- 
stand a question), advises about diag- 
nosis and treatment, explains the 
therapeutic options in the order of 
importance to the patient, offers 
opportunities to review information 
previously presented, offers the oppor- 
tunity to decide about therapy (e.g., 
whether to start with sulfa immedi- 
ately, consider another treatment, or 
wait until the results of the urine cul- 
ture are available), writes a prescrip- 
tion, prints a progress note for the 
chart and reminders for the patient, 
schedules follow-up visits, conducts 
follow-up interviews, and helps to 
guide the progress of therapy. 

In collaboration with clinicians at 
Beth Israel Hospital, together with 
members of the employee health 
department, we also developed a com- 
puter-based health screening interview 
for hospital employees. The interview 
is part of the clinical information sys- 
tem, developed by the Center for 
Chnical Computing and used through- 
out the hospital, and is available on 



48 



Harvard Medical Alumni Bulletin 



any of over 3,000 terminals. Con- 
ducted in private and with protection 
of confidentiality, the interview seeks 
information on medical problems and 
patterns of living for which behavioral 
change is considered desirable and 
offers advice and suggestions on mat- 
ters of health and illness (general med- 
ical history, nutrition history, exercise 
patterns, habits, safety, environment 
and stress). At the end of the interview 
the program offers a clinical evaluation 
of problems that could be favorably 
influenced by changes in behavior. In 
addition, en route through the inter- 
view, the program offers information 
about referral services. 

In a 5. 5 -year period ending in 
November 1995, 2,586 employees 
completed the interview. Eighty-five 
percent of the employees expressed an 
interest in the health-related programs 
offered by the hospital: 73 percent 
were interested in the fitness center 
and 38 percent in the stress-reduction 
program. The results showed that 
stress and unhappiness were common: 
57 percent of the employees reported 
high levels of stress and 43 percent 
reported feeling sad, discouraged or 
hopeless in the previous month; 6 per- 
cent indicated that life sometimes did 
not seem worth living. (As soon as 
their responses were registered, these 
people were told by the computer 
where they could obtain help for their 
problems.) 

Over the years, we have incorpo- 
rated into our programs a number of 
provisions designed to yield control to 
the patient in dialogue with the com- 
puter. With the typical interview, we 
request permission to proceed (e.g., 
"May we call you by your first name?" 
and "Would it be OK with you if we 
asked a few questions about your emo- 
tions?") and do our best to respect the 
patient's priorities, their right to 
decide (with sufficient alternatives), 
their right not to decide, to help with 
uncertainty (offering "don't know" and 
"don't understand" options, with 
explanations when appropriate), and to 
respect a reluctance to respond. 



In Wisconsin, we incorporated a 
"none of your damn business" option 
into responses to the questions. We 
have since toned it down to "skip it," 
better accepted in Boston. An 
expanded set of responses to yes/no 
type questions enables patients to indi- 
cate uncertainty and lack of compre- 
hension, to request clarification, and to 
bypass questions they don't care to 
answer. This reduces the number of 
uninformed responses and the coer- 
cion that can lead to inconsistency, 
subterfuge, and decreased validity. 
Most of our computer-based inter- 
views also employ, to some extent, 
other mutually exclusive numbered 
choices, multiple choices with more 
than one response acceptable, and 
free-text responses. 

I used to dream of an interactive 
Dr. Spock, a computer-based program 
available to the parents of a sick child, 
that would offer advice about diagnosis 
and treatment and when to seek fur- 
ther medical help. (When to go to the 
doctor is sometimes the most difficult 
of diagnostic decisions.) With the bur- 
geoning technology of worldwide 
communication, this dream can now 
be a reality. Medically useful dialogue 
can be made available on any personal 
computer, in addition to computers in 
physicians' offices, clinics and hospi- 
tals. 



In our experience, concern about 
the computer as a depersonalizing 
influence in dialogue with patients has 
been unfounded. Computer interac- 
tion thus far has been pleasant, inter- 
esting, informative and empowering 
for most patients, and has been effec- 
tive in helping them to help both 
themselves and their doctors. ^ 

Warner V. Slack, MD is HMS associate 
professor of medicine and psychiatry. He is 
co-chief with Howard Bleich, of the 
Division for Clinical Computing in the 
Department of Medicine at Beth Israel 
Hospital, and co-president with Bleich of 
the Center for Clinical CoTnputing. This is 
adapted with permission from a chapter he 
wrote for a forthcoming book, 
''Information Technology in Community 
Health " (Springer Verlag, publisher), and 
from the New England Journal of 
Medicine (2'j^:ip^-8, ip66), the 
Lancet (July: 240, 1977) and M.D. 
Computing (1:52-5), 68, i^S/f. and 
12:2^-30, i99s)- 



Spring 1996 



49 




5° 



Harvard Medical Alumni Bulletin 



The Senior Set 
on the Net 



by George S. Richardson 



In theory, the Internet should 
be a boon to disabled elderly shut-ins, 
yes, even the "old old." What could be 
better for the housebound, the bedrid- 
den, to soar off into cyberspace or to 
find themselves in a delightful romper 
room full of people who share their 
pains, joys and memories. If only it 
could be as easy as tapping just one red 
button on a keyboard! 

In actuality, as we all know, there is 
a great gulf fixed between the young, 
who are users, and the old, who are 
not. This, I believe, is not simply due 
to a lack of energy and of coping skills 
on the part of us elders — although my 
son claims that no one over 40 can 
cope with a VCR. (He forgets that the 
directions for ours were lost long ago, 
when he gave us the machine.) 

"Coping skills" is worth a paren- 
thetical comment. As doctors, we 
know that the physical problems of the 
elderly are not entirely unlike those of 
younger persons with disabilities. For 
every disability another coping skill is 
required. As a result, the elderly must 
accumulate a host of coping skills that 
healthy younger persons never think 
about. In this sense the elderly may 
properly be called the "mature!" 

Another fact of accumulated years 
and accumulated skills is that each new 
experience or challenge is a smaller 
fraction of the total. A new learning 
challenge is bound to make less of an 
impression than it would have in the 
past, so that it takes a httle more time 
and care to learn new skills than it did 



when we were young. It was not 
unusual, I think, that my brother, E.P. 
Richardson '43A, and I could learn to 
touch-type by computerized instruc- 
tion when we over 65, although nei- 
ther of us had ever typed before. 

Whatever the problems of the 
elderly, we are not naive; we already 
have our interests. Most of us have the 
skills we need to pursue them — print 
resources in the form of magazines, 
books, references and encyclopedias, 
many already on our shelves. Many of 
us have the skills to seek further in 
libraries and in their catalogues, com- 
puterized or otherwise, and we get a 
solid sense of comfort in doing so. 
Having been chairman of the MGH 
library committee for many years, I 
enjoy the help of their reference 
librarians, as well as on-line access 
from my home to the catalogues of the 
Harvard libraries and Countway 
(through HOLLIS), the Boston Library 
Consortium, and the Library of 
Congress, as well as access to the med- 
ical literature through Ovid technolo- 
gies. 

Does this mean that we don't need 
the information highway? Indeed, 
those of us who have tried venturing 
into cyberspace have found that the 
"highway" is fenced in by huge garish 
billboards on all sides and this "infor- 
mation" is mostly advertising. When it 
is not, it seems like a child's gee-whiz 
encyclopedia. The more user-friendly 
the server, whether it be CompuServe, 
Netscape, America Online or any of 



their many ancestors and descendants, 
the more this seems to be true. 

But if we're not in the market for 
information, as such, we may be in the 
market for something else. Someone 
out there in the entrepreneurial world 
has failed to tell us what it is — surpris- 
ing, in view of the fact that we are the 
fastest-growing fraction of the U.S. 
population. 

I, for one, could be sold on: (i) 
being able on any day, at any hour, to 
tour the world, seeing its natural won- 
ders, its animals, its cities, and visiting 
the universities and museums that we 
would visit on an actual tour; and (2) 
being able to find, on any day, at any 
hour, a group of people, gathered from 
anywhere in the world, who share 
some special little interest of mine. 
And, of course, I want these features to 
be (3) very user-friendly. 

America Online includes 
SeniorNet, "a national nonprofit orga- 
nization whose mission is to build a 
community of computer-using 
seniors. ...SeniorNet currently has over 
18,000 members [pretty small, huh?] 
and has helped start 75 Learning 
Centers around the United States 
where computer classes specifically 
designed for older adults are offered." 

Under this rubric, SeniorSite 
includes a host of subjects from gov- 
ernment resources to "older jokes for 
older folks." The Senior Citizens 
Opinion Forum seeks to remedy the 
observation that AARP publications do 
not provide much space for letters and 



Spring 1996 



51 



opinions. The foruin solicits articles of 
250 to 650 words on issues affecting 
the elderly. In addition, SeniorNet 
Online Electronic Community pro- 
\'ides discussion groups on a variety of 
topics (genealogy, pets, sex and much, 
much more). 

The V^^orld Wide Web has every- 
thing, including topics of especial 
interest to older people. For example, 
the home page of Michael Notte, an 
expansive Italo-Canadian, 
(http://www.niagara.com/~jmnotte), is 
interesting and informative, and it pro- 
vides gateways to a lot of elder-ori- 
ented material. Once on the Web, you 
can slum around in the Louvre (full 
coffee-table quality reproductions on 
screen!) or any of a vast number of 
sites, including MGH's Department of 
Neurology (a real funny guy lurks 
behind it). 

Back to the romper room. America 
Online provides user-friendly access 
with their "chat rooms" beginning 
with the New Member Lounge and on 
through "private rooms." Access to the 
latter is restricted to those who know 
its name, which might be "Harvard 
Medical Alumni," for example. (No, it 
does not exist yet, so far as I know.) A 
room "holds" about 25 people. After 
that, mitosis occurs and a new room is 
formed. In these rooms, participants 
can choose any screen name they wish, 
and enter by saying, "Hi, everyone" or 
whatever and leave with a "Bye" when- 
ever they choose. "Screen name" also 
means an identity that may be false, so 
that a person who ought to be called 
"Grumpy Grampa" can enter as "Cute 
Chick." 

(The whole topic of surfing in 
cyberspace with fictional identities has 
received serious treatment in a fasci- 
nating book. Life on the Saren: Identity 
in the Age of the Inteiyiet, by Sherry 
Turkic, Simon & Schuster, 1995.) 

America Online is about as user- 
firiendly as you can get, but its friendli- 
ness comes with limitations. E-mail is 
slower, access to cyberspace is limited 
and, at times, lines are loaded and 
access is impossible. That single, red 



button that accesses the romper room 
still eludes us. (Wouldn't it also be 
nice for those of us with memory 
problems to have other color-coded 
buttons: a purple button to get the list 
of children and grandchildren with 
their birthdays, green for fellow mem- 
bers of a committee, yellow for HMS 
classmates.) 

Meanwhile, however, this alum 
urges HMS to set up a clubroom out 
there with scheduled meetings once a 
week so that those of us with modems 
can dial in, make friendly or vitupera- 
tive remarks, as the case may be, and 
educate the dean. In order to control 
the size of the room, we could even be 
divided into (yuck!) "pentads." 

In addition, and in all seriousness, 
this step could prove to be a life-saver. 
Listeners to National Public Radio 
may recall an incident that occurred 
last spring. Elderly women who were 
members of an Internet club that met 
regularly in cyberspace noted one day 
that a regular member had failed to 
check in. None of them knew her in 
any way except through text on their 
computer screens. Nevertheless, they 
went to work, found her home address 
and sent police to check. The woman 
had had a stroke, and was taken at 
once to the hospital. 

As I go through the notes that my 
classmates have sent in for our 50th 
reunion booklet, I find that fewer than 
10 percent record an e-mail address. 
Just think, if we all had e-mail 
addresses, we could be a great interac- 
tive alumni association and other, 
lesser organizations would be left in 
the dust, where they belong. 

Yours to a green old age! ^ 

George S. Richardson '46 is HMS associate 
professor of surgery at MGH and was editor 
of the Bulletin yrom 19^1 to ip8o. His 
e-mail address is gsrmd@tiac.net. 



52 



Harvard Medical Alumni Bulletin 

















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